Hello,
Our team is seeking help for one of our patients. She is 20 years old and has severe hypothyroidism which requires three times a week infusions. I think she also has IBS or Crohns. We have placed PICC lines twice for her. Both times she started showing signs of local reactions within a couple of days of PICC placement. Redness and tenderness at the site and along the catheter path in her arm. The first time we looked at a possible CHG allergy due to the redness underneath the patch. And different dressings and cleaning was tried. This made no difference. After the second PICC was removed at 4 days due to continued and worsening reaction, a port was placed. Unfortunately, this also had to be removed within 2 weeks due to a similar site reaction. There was no evidence of infection or any other cause found for these reactions. The reactions all appear to be in the area of the catheter itself. She has very tiny veins and is currently having PIVs placed three times a week. Even with US guidance, it can be very difficult to find a vein. We are using BARD PowerPICCs and PowerPorts and have seen a rare reaction, but this poor girl is apparently quite reactive.
Any thoughts or suggestions would be greatly appreciated as we are at a loss as to what to do next and this is a long term problem for her. Does anyone have experience with PICCs with a different material that we could try?
Thank you,
Pam Weber, RN, BSN, VA-BC
More than likely this is not a reaction to the type of material. It sounds lilke a phlebitis due to a large French catherter in a vein that is too small for it. Are you measuring catheter to vein ratio and placing a size of PICC that will consume no more than 45% of the vein lumen? Have you done any diagnostic US to rule out thrombus formation in the vein? I would never label any reaction as an allergy without the appropriate testing and diagnosis from an allergist. Your options for catheter material are silicone and polyurethane. Most all power injectable cvads are made of polyurethane due to its mechanical strength. Does patient have other documented allergies? Metals, nickel, etc? It could be the guidewire if that is the case. I would rule out thrombophlebitis first though. Lynn
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
Thank you for the response. I had to review the chart for answers. We use the 30% rule for the catheter to vein ratio. The first PICC was 25% occupancy and the second was 10% occupancy with 4 Fr single lumen lines. The patient has no documented allergies and when I talked to her, there is a possible vague metal allergy. With the first PICC, the reaction started with hives at the site and continued to progress along the line itself. All CHG was removed from the area and different dressings were used. The symptoms resolved soon after PICC removal. With the second PICC, the patient developed enlarged lymph nodes along that arm and her neck with swelling and redness both proximal and distal to the insertion site. This occurred within 24 hours of placement. The symptoms quickly resonlved with removal of the PICC at 4 days. A similar reaction occurred along the tunneled catheter path with the port and once again resolved as soon as the port was removed. There was no evidence of thrombus found. We are currently investigating possible allergy testing vs. placing a silicone catheter. Any other thoughts would be greatly appreciated.
The reactions occuring during midline and PICC insertion have been attributed to mast cell activation syndrome. This is thought to be due to physical stimulation of mast cells which release histamine. Same signs and symptoms as an allergic reaction but not caused by IgE like a true allergy. I would definitley proceed with allergy testing to confirm or rule out polyurethane allergy. I would bet that it gets ruled out. This reaction resolves even when the catheter is left in place because it was due to the physical stimulation and not the simple presence of a foreign substance. Those occurring several hours after insertion are outside the typical picture of what I am talking about but could still be related. Mast cell activation syndrome has never been completely proven due to lack of interest in studying this rare occurrence. At least one catheter manufacturer has said it happens with all brands so they did not invest any money into studies. Mast cell physiology is well documented in many textbooks. It is the same as what happens with red man syndrome from vancomycin but that is chemical stimulation of mast cells. Only thing I can think of to add would be to ensure that all antiseptic solutions are thoroughly dry before skin puncture so you don't drag wet solution into vein. That can cause activation of complement proteins, also a mechanism to stimualte mast cells.
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