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Karen Day
Karen Day's picture
what would you do???

I recently had a patient who weighed over 600 pounds in which I placed a picc line.  When I scanned her vessel, I could see it clearly, but then it quickly dropped off the screen.  I knew that she would have some tortuous vessels, but I have encountered these patients many times and have been successful in placing their catheters into the SVC.  I measured my catheter and trimmed at 47 (insertion was mid-way up the right arm).  Catheter seemed to thread without difficulty and flushed easily and gave great blood return.  CXR showed tip in axillary, confused, I ordered a humerus X-Ray to see the path the catheter had taken.  The entire 47cm catheter was in a serpiginous vessel in her upper arm.  Due to the large size of this patient, no one was willing to place a central line either subclavian or IJ; (she required surgery to remove her submental fat just to trach her).  The doctor chose to leave this picc line in place as it is her only access for now.  It has been 5 days and it still flushes great, a little sluggish on blood return, but after tPA - did fine.  I have recommended that they do not do blood draws through this line and do circumferential measurements of her extremity as I understand the high tendency for this vessel to not only thrombose, but even infiltrate.  I have strongly encouraged the physicians to inquire with surgery about the possibility of placing a tunneled catheter, but her weight prevents her from having it done in IR.  We do bariatric surgeries here and I am hoping that the surgery department posesses a table that can accomodate her weight and do fluoro as well, maybe then they could place a tunnelled catheter.  Would you have left your picc line (or midline technically) in place or insist on it's removal and leave them scrambling for access for this patient. 

mary ann ferrannini
   I would have pulled it

   I would have pulled it back so the tip sat in the upper third of the arm so as a midline..BUT then it could only be used for isotonic or near isotonic IV solutions and for meds that fell within the acceptable Ph. Then I would have come back preferably in the same day and attempted to place another PICC and preferably with a tracking/locating system. I would have got something to help relax the patient as well. If we know we are going to do a difficult insertion we have found that it is easier if the patient is not in pain and is as relaxed as possible. We also have access to a beeter US than our bedside one and we arrange to get that one from OR. Also what about IR...could th pt have gone down there for placement??

Karen Day
Karen Day's picture
this is a midline, the entire

this is a midline, the entire 47cm catheter is in her upper arm with the top terminating in the upper portion of the arm (not really axillary vein, but near the axilla section of the arm)  I had no problem visualizing the vein for access, so a better ultrasound unit would not have helped me.  the patient is on the ventilator and sedated, so she is relaxed as she can get.  The patient weighs too much for the IR table, so that is out as well.

 

mary ann ferrannini
   I would have pulled it

   I would have pulled it back so the tip sat in the upper third of the arm so as a midline..BUT then it could only be used for isotonic or near isotonic IV solutions and for meds that fell within the acceptable Ph. Then I would have come back preferably in the same day and attempted to place another PICC and preferably with a tracking/locating system. I would have got something to help relax the patient as well. If we know we are going to do a difficult insertion we have found that it is easier if the patient is not in pain and is as relaxed as possible. We also have access to a beeter US than our bedside one and we arrange to get that one from OR. Also what about IR...could th pt have gone down there for placement??

Donna Fritz
Tunneled cath in bariatric

Don't think a tunneled cath placed in surgery will be easy . . . we had a bariatric male pt with leukemia that was sent to surgery for placement of a tunneled Groshong.  Could not locate the subclavian vein with needle passes . . . ended up doing a cutdown to find the vein . . . still  couldn't find the subclavian.  Tried a different spot in the same general region.  Pt had CXR which showed cath tip around brachiocephalic/SVC junction.  When patient sat up, the exit site sagged lower, pulling the cath further out.  I reviewed a subsequent CXR with the radiologist and he thought the cath was only 3.5 cm into the vessel, which meant that the proximal lumen exited half in and half outside the vein.  His line had to be removed because of what some thought was an infection in his chest wall (never grew anything).  Punch bx showed "spongiotic dermatitis" which seemed consistent with an extravasation of vesicant medication.  Surgery refused to touch him again, so access was an issue.  We ended up with a PICC line with several DCs and reinsertion several days later.

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