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Tue, 06/12/2007 - 19:00

DML RN

Midline for pt. with central vein stenosis?

Is stenosis of veins in the thorax a relative or absolute contraindication for a midline PIC?

Pt scenario: 60-something female transferred from another hospital after a 6-day stay for abdominal pain,as yet undiagnosed. Obese,diabetes,CHF,ARF. Arrived with a 22ga PIV in the thumb,a dozen bruises from IV tries and blood draws and no prospects for any better PIV sites. She had aÂ prolonged bout of pancreatitis in the late 70's and ended up with bad stenosis inÂ both subclavians (acc. to her,anyway--H&P didn't mention this) from CVC's and TPN. Said that a few yrs ago some IR dept couldn't get a PICC past her rt axilla. PICC ordered for her (at 3:00PM,of course)--IVF's,pain medication and antiemetics for now.

Assessment: She had a few prominent veins on the rt chest,nothing significant on the left. Left basilic small,brachials both OK,cephalic actually her biggest vein but I wasn't about to go that way,no venous aneurysms and no collaterals in the arm. I explained to her my point of view on her situation.Â Here are the parameters I had to go by: IR doesn't do IJ or EJ PICC's;our nurses never will either;she's hardly sick enough to justify a triple-lumen placed in the IJ;the stenosis may extend to the point that an IJ-placed line might not end up central,either.

Between MD,patient and myself we agreed on a midline attempt. Via left med brachial,I advanced a 4Fr Groshong to the level of what I measured to probably be brachiocephaic depth. Pulled back to Midline depth,got good blood return,no problems with flushing,etc.

So that will get her through for now,but I'm wondering if others have an opinion on this situation.

Wed, 06/13/2007 - 08:18

lynncrni

Your message did not state

Your message did not state the specific types of therapies, their osmolarity and pH. This would determine the relative risk of complications to expect from this midline. For therapies outside the parameters for pH and osmolarity, for vesicants or if therapy is needed for an extended period, my suggestion would be to refer to an IR for placement of a CVC through an unconventional approach such as translumbar vein. This would place the tip in the inferior vena cava. Femoral site could also be used, but I would not place a percutaneous line there. Might consider a tunneled catheter inserted via femoral with the tunnel bringing the exit site out higher on the abdominal area. The decision is based on a risk-benefit analysis for each patient as there are no clear recommendations in cases such as this. We know the potential set of problems when the midclavicular or midline tip location is used for therapies not recommended for those tip locations. But on the other hand, you have to do what is best for the patient. 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

Wed, 06/13/2007 - 12:35

DML RN

Not sure of the pH or osm.

Not sure of the pH or osm. of them,but there are no 'red flag' meds---1/2NS,Protonix plus prn Zofran and Dilaudid.

As of this afternoon,arm looks fine,line still has good blood return,patient feels a little better,if only for not having been poked in almost 24hrs.

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