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Dialysis patients and PICC line placement

The renal doctors ordered a PICC insertion on a pt. admitted from the E. R who had an MI and hypotension.  Assessment indicated he had a central line catheter 2 years ago on the left side and currently had a fistula on the left side also.  INR was 1.3.  No history of thrombus for 2 years.   Accessed his right basillic vein very easily and catheter advanced easily but was not able to aspirate blood unless it was pulled back 5-6 cm.  During the procedure the pt. began bleeding quite heavily around the site and his upper arm was bruising quickly and swelling.  TLS indicated the catheter was going across his chest and was not going down SVC.  Bleeding increased dramatically and the heparin drip had been stopped immediately prior to the procedure.  I pulled the PICC out, placed pressure on the site and applied ice pack to his arm.  NO further attempts were made and stat lab work was ordered to determine his clotting time.  What do you think happened and what would have been the best practice to use?  After the procedure the daughter came to the hospital and said the pt. had a port in his right chest 2 years ago and it was removed due to infection.  That information was not available prior to the insertion. 

Timothy L. Creamer
Dialysis Patient and PICC

There are variables not listed. The heparin gtt was discontinued immediately prior to procedure, though only the INR is listed, heparin affects the APTT. How hypotensive was this patient? If severely hypotensive a brachial artery may potentially be confused for the basilic vein due an absence of pulsatile presentation. This happened to me in my early clinical practice after transitioning to ultrasound and MST, a post code situation where the physicians did not want to risk a pneumothorax and failed at a femoral access. No bright red blood, no pulsatile flow, and this catheter also did not want to course downward toward expected SVC. Heavy oozing once catheter removed, extended manual pressure to acheive hemostasis. Once catheter removed and heavy oozing observed I knew what had happened, learned a valuable lesson and improved ultrasound skills to recognize a compressed artery (thicker walled). A possible scenario is the artery was accessed and why TLS indicated crossing midline. Only a possibility based on information provided. In my experience a prior port site can prevent advancing past that area versus causing contralateral tip placement. Hope this helps.

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

I second Tim's post.

My first thought was to wonder if it was arterial.

Would have been good to know what the PTT was.

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

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