This was posted on the ARIN (Assoc of Radiologic and Imaging Nurses) Listserv, I thought you would be interested.
---- "Mary K. Berman" <[email protected]> wrote:
We had a case in point just this past week! A patient came to our IR department to have her power injectable PICC rewired as she was having some issues with the line...one of the hubs of the dual lumen was cracked and leaking. She had the PICC placed for access reasons and for a continuous Dilaudid drip for treatment of her metastatic cancer pain. The PICC was initially inserted in early July 2011 at the bedside by one of our best IV team nurses with loads of experience under her belt. The post-insertion CXR was read out by a very experienced radiologist as being in the cavo-atrial junction of the SVC. So, it was ready to use...right?
We got her on the table, prepped and draped the existing PICC area and line according to our protocol, and our IR doc accessed the line by wire. Something centrally looked a little strange to him, so he injected a little puff of contrast...and it went distally to her head, neck, arms, and hands! Yeah, you all know what's coming...it was inserted into her brachial artery, with the tip in her ascending aorta near her valve...and had been there since July!!
Needless to say, the line got pulled and pressure was held for the appropriate amount of time for a 6 Fr. arterial puncture in an anticoagulated patient (she was receiving Lovenox injections for hypercoagulability seen in oncology patients). As soon as the line was out, and not reported earlier, she said she had been having an intermittent dull ache in that hand which now had changed to a "pins and needles" sensation (aka reperfusion pain?). The Dilaudid and anticoagulation in combination, most likely masked her hand ischemia and helped to prevent full occlusion of the artery below the line. Incidentally, she reported "going blind" for 2-3 days during the prior month and had tons of imaging, presumably receiving contrast for some of the studies through that line! Some brain imaging doesn't require contrast and she never had any chest imaging with that episode, which would have shown the line in the wrong vessels. They found no lesions in her head, but still passed off t he transient blindness as progression of her disease. In exploring her symptoms more, she reported her symptoms always seemed to follow "something new going into the line".
This all just makes me shudder! But it clearly illustrates that we never really know where the tip OR the line is without verification of flow. A good blood return and easy flushing do not guarantee proper placement or flow direction, just patency. And the follow-up CXR can be read incorrectly, as happened in this case (I pulled up the archived image and the CXR wasn't the best quality...the patient is quite obese and it wasn't exactly AP...the patient was on a stretcher and slightly askew, making it appear that the line was in the correct position).
So let's take this discussion a step further...should it become best practice to not only take a spot film prior to injecting (to confirm current tip position), but also to do a quick injection to establish direction of flow, especially for those lines that were NOT placed under fluoro to begin with?
These are just my opinions. I don't mean to offend any of our infusion nurses or their techniques. They are very knowledgeable and skilled at what they do...and they perform a great service to many, many patients and also to those of us in IR, who wouldn't be able to handle the additional volume of PICCs that are screened out and done by them. This case, though thankfully very rare, makes a great argument for ALL PICCs to be placed under fluoro; OR at least verified under fluoro, not just by a spot. I know that calls into play the problem of extra radiation as well as potential issues with the contrast, not currently needed for every fluoro-placed PICC...Perhaps a flow-directed wire or balloon could/should be used in each case? I'm just throwing these thoughts from "the world according to Mary" out there for discussion! I would love to hear your thoughts...the ARIN community is the best resource for everything radiology!
Mary K. Berman, BSN, RN, CAPA, CRN
Baystate Medical Center
Springfield, MA 01199