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Inadvertent arterial placement of PICC

We recently had an incident of an arterially placed PICC discovered after several weeks of treatment.

The nurse who dc'd the PICC noticed pulsing of blood from the insertion site after removal of the

catheter.   A few days later, another nurse noticed on the x-ray film that the path of the PICC was

unusual...both of these films showed the catheter rising above the level of the clavicle and crossing

the midline, rather than dropping down into the SVC.  Both these PICC's were placed in the right

arm.

  We(PICC nurses) view our PICC x-rays and release them for use...the really interesting thing was that in both cases,

(a different radiologist each time)the radiologist stated the PICC tip was in the mid SVC.  I took copies of these

films to the radiology dept. for them to use as a "teaching tool" and we have had an inservice on this

situation.   Any one else have something like this happen?

Mats Stromberg
Tanya, we have not

Tanya,

we have not experienced this and hopefully we will not need to.

For the teaching purposes of me and maybe others, could you perhaps...

- elaborate on why the arterial stick and placement was not recognized at insertion

- tell us what was administered in this PICC and how the patient reacted to these infusions/injections

- consider publishing (of course without patient data) the x-ray pictures in the IV-therapy.net gallery.

Thanks

Mats

jmooney
We had a PICC insertion that

We had a PICC insertion that was in the artery.  It looked "different" on the X-ray, and the radiologist wanted a re-xray, which was inconclusive.  We took the pt. in for a flow study and that is where we discovered it was in the artery.  The only reason we feel that this was not picked up at insertion, was that the patient was severly dehydrated, thus, no pulsating or blood flow back.

Jan

afruitloop
I had a PICC one time that
I had a PICC one time that was placed in the brachial vein, but I had gone thru the brachial artery to cannulate the vein.  Of coures, not on purpose!  I had pulsitile blood from the entry site of thePICC, but the blood gas verified it was venous blood.

Cheryl Kelley RN BSN, VA-BC

momdogz
Mari Cordes, BS RN  Nurse
Mari Cordes, BS RN 
Nurse Educator IV Therapy
Fletcher Allen Health Care
 
 
Tanya:  just saw your post many months later.  This happened at our facility.  The radiologist read the film as (paraphrased)"unusual, appears to be in left brachiocephalic vein", something like that.  I noted it traveled high over the clavicle, and dropped down left of midline.  Did blood gases - 121% for pO2!  Radiologist was very responsive and grateful for my phone call. 

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

Nadine Nakazawa
Tanya:   Can you write up

Tanya:   Can you write up an article for JAVA on this case?   I've hit the artery, but I knew it (the PICC pulsated as it stuck out of the upper arm), and have never left one in.   In a patient with relatively low BP (eg, end-stage heart failure) it may not do so.  Cynthia Chernecky, the new editor of JAVA, will help you if you don't feel comfortable writing.  Just do the best you can.  We'd all love to see the CXRs.   

Nadine Nakazawa 

Nadine Nakazawa, RN, BS, OCN, CRNI, VA-BC

[email protected]..
T. Nauman RN, CRNI  IV

T. Nauman RN, CRNI  IV Educator SHMC Eugene, OR

I just located my xrays that show this.  I would like to write this up eventually...I am having surgery on Wednesday.  Mayber I can get started on an article while I'm an home for a few weeks.

T. Nauman RN, CRNI

smarison
We just had an arterial
We just had an arterial placement last evening.  The first xray reading was that it crossed the midline and looped up to the inominant vein.  Second xray the resident radiologist said he could see the aortic arch which meant it was in the artery.  NO bright red blood or pulsating, but interestingly enough when I attempted this pt on the right side I couldn't find one vein that would seperate from and artery.  Susan
momdogz
[quote=Tanya Nauman] We
[quote=Tanya Nauman]

We recently had an incident of an arterially placed PICC discovered after several weeks of treatment.

Tanya -  I'd be happy to help you write it, and/or provide some information about our case for your article; I was thinking about writing our case up also.  In our case, the PICC RN who inserted the PICC could note NO signs that she was in an artery.  The patient was an ICU patient, I believe he was hypotensive, but don't remember the rest of the details.  We had a case study in our dept. after this - it was unusual in that it was a senior PICC nurse, and she was shocked to discover that it was arterial - AFTER she placed it. 

[/quote] Mari Cordes, BS RN 
Nurse Educator IV Therapy
Fletcher Allen Health Care

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

fizerjk
Arterial PICC

Unfortunate. This may be an increasing problem, in particularly in patients with the use of tourniquet in patients with lower blood pressures, and those with implanted LVADs. The use of EKG technology will not protect us from this either. If these catheters are in for extended periods of time I cannot stress the importance of using care and not removing these lines without a thorough ultrasound exam to r/o an arterial thrombus and devastating cardiovascular or cerebrovascular events. This should only be done by vascular surgeons or interventional radiologist.

Jeffery Fizer RN, BSN

lynncrni
 I am not sure I understand

 I am not sure I understand why you think arterial placement might be an increasing problem. If US is used by an knowledgeable inserter , arteries and veins can be distinquished from each other. I agree that ECG will not provide information about arterial vs venous placement. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Abardin
Inadvertant arterial cannulation

I think we need to keep in mind that inadvertent arterial puncture and cannulation DOES occur and has NOT been eliminated with ultrasound use therefore assessment during insertion, dilation, post insertion pain and if needed a secondary method of confirmation. If the x-ray doesn’t look right or you question blood flow an ABG or distal lumen transduction is a quick second confirmation.
The primary variance in inadvertently accessing the artery is patient condition during insertion, anatomical variance and ultrasound skill set.
More importantly each of you highlight cases in which a chest x-ray was relied upon for catheter clearance. I must stress we are trending away from x-ray as the gold standard and several teams no longer do x-rays if using tip technology.
ECG/Doppler tip positioning technology is the only technology currently available to detect antegrade and retrograde blood flow via (Doppler), telling me if I am inadvertently in an artery. Personally with the way we are advancing we will rely less on radiology and more on this type of bedside technology.
Lastly arterial cannulation usually comes with pain and or numbness. The patient may complain of a heavy arm or numbness or tingling of the pinky and ring finger in the effected hand. These potential side effects should be well known by all staff working with PICC patients.

 Amy Bardin 

RRT, MS, VA-BC

jill nolte
mislabeled xray

Recently I had a panic call to remove and replace a picc the radiologist identified as arterial placement with a right side approach.  I'll spare the process of discovery, but the picc was a nicely placed left venous catheter.  The patient had a lot going on in the chest and it was difficult to identify much of anything really.  Basically the event was an error in the xray tech mislabeling right and left side on the film. 

lynncrni
 I know arterial placement

 I know arterial placement happens as I have some legal cases involving this situation. I am just curious about the statement that arterial placement was expected to increase from a previous message. Just wondering why the anticipated increase. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Linda C. Smith
Inadvertent arterial placement of PICC

First, I do not work for any company.  That said, I have been placing PICC lines at the bedside for 10 years using ultrasound.  We have been using the VasoNova VPS by Teleflex for the past year and a half and the doppler combined with ECG technology is designed to prevent the nurse from completing a PICC insertion in the artery.  As the catheter is threading we can also see the doppler waveform.  So if we are tring to thread into an artery the device will immediately show us the "red stop sign" and we can also see that the flow is retrograde.  I do not know why more Arterial placements would be anticipated.  I would think that with advances in ultrasound technology it would be easier to identify the artery.

Linda C. Smith, RN

Constance
The VPS Triple Vector Will Stop Inadvertant Arterial Placment

I do not work for Teleflex, but use their technology. I opted for this technology because it uses ECG, Doppler and an algorithm. After years of using the very subjective single technology of the CXR I didn’t want to depend on another single vector technology like ECG alone.

Arterial placement should not be on the rise. Good assessment with the ultrasound and knowing vascular anatomy should keep inadvertent arterial puncture to a minimum.

 In the rare cases were the catheter is placed in the artery, or the  azygous vein or IJ  even contralateral IJ the VPS Doppler sensor detects that the catheter is being advanced AGAINST blood flow and NOT towards the lower 1/3 of the SVC.  I have not had an inadvertent placement in any vein other than the lower 1/3 since I began using this triple vector technology let alone an artery.  My malposition rate has gone from 3.5% to ZERO! It is empowering to walk away from a patient knowing that the device is placed precisely where you want it and you can release it for immediate use.

 

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