Has anyone ever had a patient that was getting PPN through a midline develop a DVT in their subclavien vein and jugular on the same side. If so, how does this occur? The midline was the patient's only vascular access prior to the DVT development with no prior venous access attempts. The midline vessel was a very large basilic vessel.
Thank you.
2 questions come to mind. Are you certain that the tip location was correctly positioned in the upper arm level with the armpit and not advanced too far into the axillary vein which begins at the head of the numerous and extends across the front of the shoulder? What was insertion and length of catheter inserted?
And what was the final osmolarity of the PPN solution? This can range from 735 up to ~1200 and still be a PPN solution?
The thrombus could be due to mechanical damage to the endothelium from tip location in the shoulder area. And it could be chemical damage from the hypertonic solution. Anything greater than 350 mOsm/L is hypertonic and greater than 900 should not go through any peripheral vein which includes midlines. Clots start at the area of damage but grow or propogate to include a longer length of vein. Subclavian and IJ join together near junction of first rib and sternum, so it can extend into IJ.
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
Lynn, it was ultrasound guided and the catheter length was 10 cm. It was in the upper part of the arm but below the axillary vein. The vein size was very large and healthy all the way up. The solution of the PPN was confirmed with pharmacy to be PPN concentration but I don't know the specifics. The original placement was for a PICC line but the patient didn't like the idea of having the catheter in so far in but was agreeable to the midline and PPN. I spoke with the nutrition doctor and pharmicist about the plan for midline and made sure they were onboard with PPN concentration. She started complaining of arm pain and had some mild swelling around the 2 1/2 week mark. I just couldn't figure out how this could happen so far beyond the catheter tip. Very strange.
Laura McRae, RN, BSN, CRNI
Midline insertion requires careful measurement between the insertion site and tip location level with the armpit (axilla). For a 10 cm catheter inserted mid-bicep, the patient would have to be very tall to have a correct midline tip location. So that midline may have been much farther into the vein than you think. Also, you need to know the final osmolarity of this PPN as the inserter as a major characteristic of the infusate. This is a huge component of your assessment and I would never proceed without that information. MD and RPh may not have the knowledge of what extremely hypertonic flluid can do to a vein. 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