A problem we have seen in our practice is PICCs malpositioning within the subcutaneous tissue of patients with one or more of the following: a large arm (circ >40 cm), excessive pistoning motion with arms (wheelchair-bound patient who self-propels), and/or extremely poor muscle tone in the upper arm.
This type of malposition produces the same symptoms as intraluminal catheter occlusion - leaking and sluggish flush, with or without blood return. We have replaced these lines up to two times in the same patient within a period of about a month, because the complication repeats itself continually until therapy is completed. Since identifying this trend, when we have a patient with the aforementioned criteria present with these symptoms, we immediately order a xray to evaluate PICC position. If a malposition is revealed we strongly urge the physician to place a line in a different location if IV therapy is the only effective route. One of the dangers we have observed is a PICC that had ruptured because it had been kinked for so long, placing patient at risk for extravasation injury and catheter embolism.
Has anyone else encounterd this issue/have any recommendations on how we can better serve these patients?
I cannot see the full course of the PICC on your photo. But for a PICC to go through the vein wall and into the subcutaneous tissue would be unlikely since the PICC is so soft and flexible. Vein damage on insertion could happen if the guidewire is long and advanced past the shoulder without fluoroscopy. This could set up the problem. What type of fluid is leaking from the site - serous, bloody, clear? This could be lymph, bleeding from the local site, or retrograde flow of infused fluid. If the tip is outside of the vein, there would be no blood return but problems inside the vein can also cause no blood return. Where are you leaving the tip during the insertion procedure? Those ruptured PICCs had to present with difficulty flushing before it ruptured. So why are nurses using so much force to flush? This is definitely a lack of knowledge and skill.
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
Can't even imagine what your talking about. In all my years I have never seen nor heard about that type of problem. I think Lynn hit it right on point, experience and knowledge.
This is very interesting. I serve a large population of obese patients. I have never seen this. I have a couple things that come to mind quickly and a couple points of clarification needed.
1. This coiling is that external or internal?
2. How was the insertion process?? tip in proper position and catheter was inserted easily and with no resistance when inserting catheter via the introducer and the last portion once the introducer was removed?
It makes me think the catheter was pushed in and did not go in easy and then kind of looped up. You know how you can insert the catheter and it will go in but be kinked etc..... but....you usually never get blood return, or even get a full occlusion.. Is this happening???
2. Are they keeping the stylet in the PICC for the entire insertion? What does the stylet look like upon removing it?
3. Was this evident up competion of the initial insertion immediatley or days later?
4. Was there any catheter left exposed externally?
5. Where was the tipp of the PICC confirmed to be upon initial insertion?
6. What vein did they use for insertion? Did they pre assess to see no bifurcations, or that they entered the vein above?
Gina Ward R.N., VA-BC