Is stenosis of veins in the thorax a relative or absolute contraindication for a midline PIC?
Pt scenario: 60-something female transferred from another hospital after a 6-day stay for abdominal pain,as yet undiagnosed. Obese,diabetes,CHF,ARF. Arrived with a 22ga PIV in the thumb,a dozen bruises from IV tries and blood draws and no prospects for any better PIV sites. She had aÂ prolonged bout of pancreatitis in the late 70's and ended up with bad stenosis inÂ both subclavians (acc. to her,anyway--H&P didn't mention this) from CVC's and TPN. Said that a few yrs ago some IR dept couldn't get a PICC past her rt axilla. PICC ordered for her (at 3:00PM,of course)--IVF's,pain medication and antiemetics for now.
Assessment: She had a few prominent veins on the rt chest,nothing significant on the left. Left basilic small,brachials both OK,cephalic actually her biggest vein but I wasn't about to go that way,no venous aneurysms and no collaterals in the arm. I explained to her my point of view on her situation.Â Here are the parameters I had to go by: IR doesn't do IJ or EJ PICC's;our nurses never will either;she's hardly sick enough to justify a triple-lumen placed in the IJ;the stenosis may extend to the point that an IJ-placed line might not end up central,either.
Between MD,patient and myself we agreed on a midline attempt. Via left med brachial,I advanced a 4Fr Groshong to the level of what I measured to probably be brachiocephaic depth. Pulled back to Midline depth,got good blood return,no problems with flushing,etc.
So that will get her through for now,but I'm wondering if others have an opinion on this situation.