Hi,
I work in a large teaching facility where 2 PICC nurses are partnered at the bedside for PICC insertions.  We use Modifiedi-Seldinger technique with ultrasound and advance PICCs slowly. A directional device rests on the patient's chest. We have witnessed a rare complication of inserting PICCs that has us concerned and I am wondering if others have experienced similar problems and how to best treat the patient. Here is the issue: Mostly in the cystic fibrosis population, at the completion of PICC insertion, with the final flush, patient's  experienced lips tingling, light headedness/almost fainting, eyes rolling back, facial flushing and throat closing up. One patient went into respiratory arrest (he was a patient who was admitted with ulcerative colitis, who had a CABG done 2 months earlier). That was my first experience. Luckily we were in a room just outside of the nursing station and the staff response was quick. The physician called it a "vaso vagal" response. In the few instances since, we have found that retracting the PICC 2-5 cm has reversed the symptoms immediately and the vital signs taken at that time are fairly normal for the patient. If we retracted 5 cm, we re-inserted most of that, to our original measurement. Chest X-Rays are revealing the tip in the mid to distal SVC. Some patient's have had Ativan IV, others have not. The PICCs have remained in place for the duration of therapy and no further problems noted. One patient came in 2 months after his first PICC and needed another. He had a repeat of the first experience, lasting 30 seconds, which resolved with retraction of PICC. Has anyone experienced situations like this? Does anyone know what this response is caused by and how it can be prevented? I appreciate any and all feedback. Thanks, Tessy
Mast cell activation syndrome, idiopathic anaphylaxis or anaphylactoid reaction are all names for the same thing and your signs and symptoms sound like this is what you are seeing. If the vital signs did not change, I have doubts about it being vaso-vagal. I am not sure if retracting the PICC was actually cause and effect or if it was coincidental as these episodes can resolve quickly. Although the cause is different, mast cells are releasing histamine just like a severe allergic reaction or anaphylaxis. But this is not produce by the IgE antibodies that produce an allergy. Rather it is a physical or chemical stimulation of the mast cell. You did not mention the other possible allergies that your patient has. I would refer this patient to an allergist as the work-up for this is to rule out all allergies first. Hope this helps, Lynn
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
Hi Tessy, I was really shocked to read about your experience! Just last week, I was inserting a PICC in an 80 y.o. female who was fine during the whole procedure. Talking, no problems, until the very end. She suddenly says she can"t breathe, I take the mask off her and just as I'm about to put the dressing on, she turns beet red, rolls her eyes back and doesn't respond to my yelling her name. My partner put her on O2, and we called a "rapid response". Of course, during all this the PICC becomes dislodged. However by the time the RRT arrives, she's back to her baseline. She was fine. After some time passes, we insert the PICC again, and she does the same thing again, only this time, I had the PICC dressed, luckily. She ended up being fine, but I would love to know what it was all about. Vagal was the explanation I got as well.
Thanks for any input.
lme PICC Team Clinical Leader
Is anyone having trouble with the Microclave?
Here are 2 published articles that also discuss similar events. Originally this was linked to the catheter material known as Aquavene. Many thought that this material was the cause of an anaphylactic (IgE mediated) reaction. The company had information at this time that an allergic reaction was not occurring. As you can see by the second article and by your experiences, these reactions do happen and are associated with the insertion of catheters made from other materials. So the original idea about the Aquavene material was wrong. All catheters made from Aquavene were removed from the market in Sept 1996. I still believe this is a physical stimulation of the mast cell caused by the catheter advancement up the vein although no studies have confirmed this yet, probably because the numbers of this problem are so very small.
1. Vanek V, Kupensky D, Thomson D. Hypersensaitivity-like reactions related to insertion of Aquavene-based midline and PICC catheters. Journal of Intravenous Nursing. 1997;20(1):23-27.
2. Haworth C, Niven RM, Moorcroft A, Phillips A, Dodd M, Webb A. Acute anaphylaxis following midline cathertisation in a patient with cystic fibrosis. Thorax. 1998;54:747.
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
Both of the articles were excellent. Any other responses from the IV gals out there?