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sesymons
swollen arm after PICC placement
(Lots of issues this week.) Partner placed a line on saturday on a bulky guy. It was malpositioned so he tried to reposition it but of course it just got worse.  I went in on sunday and did an exchange and it went in perfect - no other manipulation needed.  Nurses started using it monday because of confusion whether it was good to go. On tuesday they stopped using it because his arm got swollen.  I ordered duplex which was negative and of course heat and elevation. He was good with the heat but not the elevation. Wednesday found that the duplex was negative and the swelling had gone down but still a little puffy on the lower are and in the hand where he had had a PIV but i had pulled when I placed the picc.  I didnt think it was swollen then. I wanted to pull the line and place in other arm but by now this guy is needing control and dying to leave for 1 month home Abx. He was sure the PICC was not a problem. My big worry was infectious phlebitis and explained it to him but he was leaning towards "the picc is not the problem, they have beat my arm up already". Final result was that we decided he could go home with it and continue the heat and if any problems develped to come back and have it done in the other are".  Did I do wrong??
Robbin George
Not familiar with the term
Not familiar with the term "Infectious Phlebitis"--Could you explain?

Robbin George RN VA-BC

lynncrni
There are 3 causes of

There are 3 causes of phlebitis - mechanical, chemical and infectious. Infectious phlebitis would be inflammation of the vein that is also infected. It could also be known as supporative thrombophlebitis if there is pus draining from the puncture site.

No I do not think your judgment was wrong with this PICC. You did not state which vein was used or what size catheter was chosen. But think about the fact that the vein lumen was filled with flowing blood until you placed the PICC. The catheter now takes the space where blood was flowing. If the catheter was large and/or you used the cephalic vein, the available space left for blood to flow was decreased. The other veins have to take up this blood flow. So it is possible to see edema especially in the forearm after a PICC is placed.

 With the additional manipulation of this PICC and vein, I would also be concerned about thrombosis but your duplex ultrasounds ruled that out for now. Heat, rest, and elevation is the best thing for now with careful assessments. If this does not resolve within 1-2 days, then it is time to do more diagnositic studies and possibly pull this PICC. 

 

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

afruitloop
There are some great articles

There are some great articles about he specificty of ultrasound in the detection of thrombosis.  Unfortunately, it is not an exact science.  It sounds like your patient certainly had some reason for thrombosis with the manipulation and replacement of the PICC. I would think watchful waiting woud be indicated initially, but if the edema etc does not resolve, repeating the doppler or a more precise diagnostic study would be indicated. 

Cheryl Kelley RN BSN, VA-BC

Rhonda Wojtas
I am glad someone else has

I am glad someone else has brought this issue up. I have been meaning to ask the same question but have not had the time. I had 2 issue with 2 different patient in the past 2 weeks. The 2 patients  had the edema of the lower arm and elbow area. NO redness or swelling at the insertion site and flushe well with a good blood return. Both of these PICC's were placed by the radiologist not the PICC line nurses. Our program is very new only 3 months and were are just finishing our training so IR still puts some of them in. Anyway, I had the nurse call the medical doctor and get an order to re consult IR for eveluation. In both cases the ultrasound was negative for any signs of DVT.

 I really felt that the edema was not and infection or problem with the PICC line. I felt that the line after being checked by US to were ok. I am not sure what happen after and if the lines were left in or not.

 I am so glad to be here to be able to get information and feed back from this group.

Rhonda Wojtas, RN VA-BC

kfarr
dvt

if a dvt is suspected how long should we stay away from the arm. i have heard at least 6 months is this true.

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