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dotave
Mid Line infiltration

I have a patient in a nursing home with a mid line in his left arm ( this is an affected arm from a stroke) that has been in for only 2 days.  He has been receiving IV fluid at 75cc/hr, his left hand started swelling one day after insertion and the edema has increased over the past 3 days, he now has 2 plus pitting edema up to the insertion site. Twice the IV team that we contract with have come to assess the swelling and the patency of the mid line.  They suggested elevating the arm,and that the line was patent and OK to use.  I went in to assess the line, it flushes fine but, I was not able to get a blood return and it was leaking from the insertion site, I d/c'd the line.  I also work on an IV team and we remove lines that are leaking from the site.  My questions are: 1) should you always get blood return from mid-lines ?  2) if a mid-line is infiltrated is it possible that swelling could occur below the site?

Sharon Irvin, RN, BSN

lisayrn
Lisa Y., Team Leader IV Team

Lisa Y., Team Leader IV Team UPMC St. Margaret Pittsburgh

In my experience, if the line is a 3 or 4 fr you may not always get a blood return from a midline.  If the swelling is below the insertion site I would be concerned about a blood clot not infiltration......especially with someone who already has circulatory issues in the extremity.

 

Lisa Y., RN, BSN University of Pittsburgh Medical Center/Horizon IV Therapy

dotave
Thank you, Lisa The midline

Thank you, Lisa

The midline was a 4 french, I didn't think blood clot because the swelling is pitting edema, but I will look into it.  What are your thoughts about leaking from the sight?

 Sharon

Sharon Irvin, RN, BSN

lisayrn
Lisa Y., Team Leader IV Team

Lisa Y., Team Leader IV Team UPMC St. Margaret Pittsburgh

Leaking from the site could be r/t any number of complications, including a clot, split in catheter(maybe someone was using a syringe smaller than 10cc??), etc. At any rate......pulling the line was the right thing to do.

Lisa Y., RN, BSN University of Pittsburgh Medical Center/Horizon IV Therapy

karrenberg
Since a midline is
Since a midline is considered a peripheral line it behaves like a peripheral in regards to blood retrun.  When new, both will  give great blood retrun. but after awhile if the vein starts to get irritated you may not get blood retrun.  A lot  depends on how sensitive the patient's veins are and what they are geting.  If someone is on continuous fluids and three or four piggybacks of various meds, you will lose your blood return pretty quick.  If someone is getting daily Rocephin and nothing else, you probably won't have any problem at all. 
lynncrni
You are overlooking what I

You are overlooking what I would consider to be the most important factor - the catheter was placed in the arm with paralysis from a previous stroke. This is always a strict contraindication for a PICC or midline catheter. The paralysis prevents the muscle pump action, which is the primary means for blood to return to the heart. Muscle contraction compresses veins and pushes blood back to the heart. When this normal function can not happen, the patient is at risk of vein thrombosis due to altered blood flow - one of the three components of the Triad of Virchow. Now the catheter is present, also altering blood flow due to its presence and probably endothelial disruption. So that is now 2 of the triad. There is no question that this catheter must come out ASAP and this needs to be a big lesson for the team that placed it - no catheters of any kind in a paralyzed arm. I learned this lesson the hard way myself back in the early 1980's when we began placing PICCs - also a PICC placed in the paralyzed arm of a stroke patient and he developed a serious clot along the catheter. Lynn

 

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

www.hadawayassociates.com

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

dotave
 My thoughts exactly, thank

 My thoughts exactly, thank you.  I did speak to the nurse manager today and said that the line should not have been placed in the affected arm.  I also asked for them to check for a clot.  I removed the line that evening.

Sharon Irvin, RN, BSN

Sharon Irvin, RN, BSN

lynncrni
Guess what they say is true

Guess what they say is true - great minds run together!! Thanks, Lynn 

 

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

www.hadawayassociates.com

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

Halle Utter
My first thought was why is

My first thought was why is the line in the affected arm?  I would need more information from the clinician who placed it.  Does the patient have some movement, just suffer weakness?  Is it totally paralyzed?  I can't imagine why one would chose that arm.  The other advantage of using the good arm, other than the obvious (that it is the correct clinical choice!) is that if the other arm is weaker or paralyzed, it is tougher for the patient to remove it!  That may sound terrible to some of you, but I work in this population frequently, and self removal can be a real problem! (Not that I can blame some of the patients!)  But I have a lot of questions for the PICC service that placed this line.  As Lynn noted, it is CONTRAINDICATED!  

 

Halle Utter, RN, BSN

Intravenous Care, INC 

Hallene E Utter, RN, BSN Intravenous Care, INC

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Hope you got that doppler?  Clot no doubt!

kathy

Kathy Kokotis

Bard Access Systems

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