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Mats Stromberg
Reaction after alteplase

Hi listers,

Could you help me explain this:

Breast cancer patient receiving adjuvant chemo (FEC). First treatment was given through PIV and yesterday pt was scheduled for treatment #2. She had had a venous access port implanted a week ago and we planned to use this for the chemo.

Flow by injection was OK, but no blood return or gravity drip possible. No coughing, twisting, turning, sitting etc. etc produced a blood return. We then installed alteplase (2mg) for 50 minutes and got a perfect blood return. The strange thing was that when flushing with saline at this point, the patient jumped in bed and complained of stinging pain over sternum approximately 10 cm from the port body. No pain when not injection and instant pain again when injecting several tries. When the physician came to look - no pain on injection.

We decided to go for PIV this time also and to do a dye study before next treatment. When I instilled heparin to pull the access needle, the pain came back.

What was this? Have you experienced this?

Mats in Stockholm

Gwen Irwin
I would be most interested

I would be most interested in the results of a dye study.  I have not had this type of reaction from anyone.

Gwen Irwin

lynncrni
Was this catheter placed on

Was this catheter placed on the left side? You also did not state the original tip location of the implanted port after insertion. These are critical factors. Catheters inserted from the left side are more prone to abutting the right side of the vein. The left side requires a longer length of catheter to be properly positioned at the cavoatrial junction. The catheter was probabaly impinging on the vein wall producing this pain. If allowed to continue it can erode through the vessel wall leading to a severe infiltration/extravasation injury into the mediastinum. 

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

Mats Stromberg
Thanks Lynn, the port is on

Thanks Lynn,

the port is on the pts left side, so catheter would be coming from the left and if too short might impinge on the vein wall. I did not know that this could cause pain this way.

All we have regarding tip position is that tip position was checked with x-ray during implantation and that tip position was "correct". What this surgeon on another hospital means by this I am not sure of, though. We will know after our own dye study.

If too short, would it be safe enough to leave it for 12 weeks and 4 chemo courses? I guess not, she's getting epirubicin? Get rid of it and place a PICC?

Mats

lynncrni
First, I would advise that

First, I would advise that you never accept a patient without knowing the exact anatomical location of the catheter tip. "In good position" or "correct position" is not sufficient information. If this catheter is too short, it is not acceptable for any medication, especially cancer medications. Epirubicin is a vesicant and this catheter could erode through the vein and cause an extravasation injury in the mediastinum. This port can be revised with a properly positioned tip located at the cavoatrial junction. 

 

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

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Is the port tubing separated from the port stem.  Curioius to the dye study.  Could it be pinch off as well and there is a crack in the port tubing (although it was a brand new placement)

My last thought is a fibrin sheath that encapsulates the catheter allowing for retrograde flow?  This could be a hypercoagulable patient.

Kathy 

 

 

Kathy Kokotis

Bard Access Systems

Mats Stromberg
Thanks Lynn and
Thanks Lynn and Kathy, update on Monday, after radiology. What labworks to check hypercoagulability? Mats
Mats Stromberg
Hi again, dye study Monday

Hi again,

dye study Monday showed catheter tip in the internal mammary vein and covered in a quite large fibrin sheath that did not let any dye go out at the tip. I strongly suspect that this catheter was NOT checked with radiology at implantation, but rather the doctor just says it was.

Could the tip have moved from a good position in the cava to this position??

Today Tuesday the patient got a new port implanted with tip at CAJ (clearly stated in pt record) by different doctor at other hospital.

Mats

lynncrni
Anything is possible, but

Anything is possible, but moving from the CA junction to the internal mammary vein is not a common location for tip migration. I also suspect that it was never in the proper locations to begin with. 

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

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