Patient scenario--70-some yr old male,came in with a big abdominal aortic aneurysm and besides repairing that they had to do an axillo-bifem bypass. POD 2,he was vented,SBP's in the 70-80's,kidneys failing. Nurse placed a PICC on right side but after 3 CXR's it was still curled in the chest. IR adjusted the line,supposedly into the SVC. Later that evening the patient had a line placd into left subclavian for Prisma. The CXR done after that line placement showed the big dialysis line in the lower SVC,the PICC on the right side of the mediastinum,more or less pointing down but with the tip about 4 cm away from the tip of the other CVC. It wasn't until late the next morning that someone looked more closely at the films and realized there might be a problem. ABG's off the PICC were identical to peripheral arterial sticks. So for 24 hrs or so,this guy was getting all of his IV meds arterially-Lasix,insulin,pressors and more.
Wait,it gets better. The RN received an order from one of the guy's MD's to leave the PICC for arterial samples,just get another PICC. What next? So I start to set up for one,when the NP shows up and decides maybe the guy needs a CVC other than a PICC. Well,he has a line in the left subclavian,the area of insertion for the right subclavian is where the incision is from the bypass,I don't know how this happened but he has a 2nd degree burn on the right side of his neck where an IJ would go in. That leaves the left arm or the left IJ. 3 phone calls and 30 minutes later everyone finally agrees that I can procede with the PICC. Routine procedure and I made sure they got the arterial PICC out.
So what happened? We just got our PACS system and I hope to be able to share the CXR films some day. First,the nurse went in on the right side,and the axillo-bifem bypass was taking some blood from the right arm. Combine that with SBP's in the 70's and I can imagine an artery that on US wouldn't show obvious pulsations. Second,the right-side PICC never crosses midline and the tip is relatively low and on the right of midline. I looked at the films with 2 Rads and they said there was nothing that really jumps out as it being arterial. The one thing I still want to do is look at the films with the surgeon--it seems very probable that IR managed to get the PICCÂ into the graft. This would account for the line pointing down and not crossing midline.
Any thoughts?
It was very interesting to read your clinical situation.
According to one of our radiologists, when a PICC is placed through the left arm, it can be easily distinguished on the chest x-ray film that whether it is an arterial placement or not because the arterial PICC on the left arm will not cross the midline to the right side due to our body's anatomical structure.
However, if a PICC is placed through right arm, sometimes, it is not readily distinguished on the chest x ray film that whether it is placed through the artery. Because of this reason, it is important to look for any clinical indications to spot right arterial PICC placement.
First,re: the CXR's. I saw the first ones--the line looked to go into the graft on one of the first tries,though only an inch or two. I had the surgeon show me where the graft ran,and it was placed very lateral to the mediastinum. The PICC,to his view,was sitting just above the aortic valve though he agreed the CXR was deceptive.
As for medication problems,hard to say. They were dumping into the aorta--really all that was going on was that they were not going through the pulmonary circulation before going out to the periphery. Clinically he had improved during the period the PICC was in the aorta. That might be misleading since he had been on Prisma for about 16-20 hrs by the time I saw him.
In the end,the multi-system failures were too much for him and he passed away a few days ago--after the second or third code,the family decided to withdraw.