The other day there was a gentleman brought to our ER for an evaluation of a PICC that had "migrated out 2 inches" at a local nursing home. When I saw him we had an x-ray showing the PICC tip in the upper SCV. He had only a gauze bandage over the site, and he had the worst case of contact dermititis that I have seen, presumably from the transparent dressings that they had been using It took 2 chloropreps just to clean the area around the site and remove the drainage that was sitcking his hairs together. There was pus draining from the PICC site itself. We did, of course remove the PICC and culture the drainage. The ER doc was not fond of the idea of placing another PICC, and I wasn't sure that was a good idea to do that right away either. The plan was to send him back, do the next few doses (Vancomycin) in a PIV, and send him back to the ordering hospital for another line once we were sure he wasn't going to be septic from the infected PICC. What happened is that he was taken to another hospital that afternoon and a PICC placed in the other arm. They had not been able to place a PIV.
So my decision not to push the doc into ordering a PICC placement has been questioned. Any thoughts from anyone would be appreciated.
Gail
You definitely did the right thing by taking the infected PICC out. The decision to place another CVC of any type depends upon the patient's acuity level. What was the original reason for the PICC? What was he receiving thru it? Did you also draw blood cultures? If this was a local site infection, another PICC in the opposite extremity could easily be placed immediately. If he has signs and symptoms of bloodstream infection, then is acuity comes into the picture. If he is stable, a new PICC may be indicated immediately. If he is not stable, he may need several days of IV antibiotics before another catheter is placed. The problem is that Vancomycin peripherally carries lots of risk of extravasation injury and the pH will always be less than 4, outside of the safe range for peripheral infusion. I would not want to have any long term care facility assume the proper assessment of Vanco through a PIV. It sounds like their knowledge and skill with infusion therapy is very limited and he could end up with a serious peripheral problem. This is a judgment call based on patient assessment. Sounds like your judgment and that of the other facility differed.
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