I work in the Home Infusion arena and recently our agency had a patient whose PICC line severed and migrated to the right atrium. Patient was sent to the ER and had the catheter emboli removed without any further problems. When I reviewed our policy and procedure manual it states “Upon discovery of a severed PICC line immediately place a tourniquet on the upper arm above the IV site. Keep the tourniquet on the arm, checking to be sure the arterial circulation is not cut off.†Is this the latest standard? It seems to me that the best nursing practice would be to lay the patient on their left side and call 911. Can anyone share their P & P or a published article on this?
The left side position is for air emboli. This will theorectically move the air bubble to the lower portion of the right ventricle and away from the pulmonary artery. This has never been recommended for catheter emboli and would probably not have the desired effect. Placing the tourniquet on the arm is based on the theory that you might be able to trap the catheter segment in the peripheral portion of the vein before it migrates to the heart. Many times the nurse would have no way to know when the break occurred. If you witnessed the break, the tourniquet could be effective. If you do not know when the break occurred, it is probably not useful. Also, with PICCs now placed in deep veins, a tourniquet would not be useful to compress the veins enough to trap the catheter. After all, the basilic vein used for PICC insertions today is a deep vein lying within the same protective sheath as the brachial arteries. So a tourniquet applied to not impact arterial circulation would have no benefit on a PICC in a vein of the same depth as the artery. A catheter and air emboli should both be treated as a sentinel event requiring a root cause analysis so that you can prevent it from happening again. Lynn
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
Could you please share with us the possible causes of this PICC embolism? What kind of the catheter?...
It was a single lumen Vaxcel PICC. The patient although instructed not to, while going to the bathroom, put her IV bag while connected to her on the floor and blood backed up into the system. When she attempted to flush the line she was unable and called the on-call nurse. The husband then tried to flush the line and was unsuccessful. The patient was sent to the ER due to the late hour and the ER attempted to flush the line and discovered wetness under the PICC dressing but did not remove the dressing or assess the PICC line. They sent the patient home and instructed them to have the Home Infusion Nurse assess the PICC line in the morning. When the Infusion nurse saw the patient the next morning and removed the dressing there was only the hub of the PICC line left. She was sent to the ER and xray confirmed that the line had fractured and was in the right atrium.
Carole Rumsey, RN, CRNI
Home Infusion Program Manager
Sutter Infusion and Pharmacy Services
Sutter Care at Home
Northern CA
[email protected]
Carole,
Was there any previous issues with occlusion from this catheter or is it just this one incidence? How did the people involved in the flushing did it? This situation begs the question was catheter flushed excessively?
Angelo M. Aguila, MSN, RN, VA-BC
Vascular Access Nurse
[email protected]
This was a new PICC line that had been placed in the hospital a few days before. There was no previous issues with occlusion. The main problem was that the patient, against nursing instruction, put her IV bag on the floor and blood backed up in the line. My gut feeling is that excessive force was used either by the husband or by the ED staff when flushing the line.
Carole Rumsey, RN, CRNI
Home Infusion Program Manager
Sutter Infusion and Pharmacy Services
Sutter Care at Home
Northern CA
[email protected]