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netty10453
tpa extravasation

should an xray for tip placement be done before using tpa  to establish a blood return ?  we have a patient with a triple lumen with " tip probably in proximal svc" tpa was used for no blood return proximal and medial port, now patient has a huge ecchymotic and red looking area right side of chest, an M.D. feels maybe the tpa was given subcutaneously.  Has anyone seen a tpa extravasation?

maureen lawler
Why are you using a PICC
Why are you using a PICC line whose tip placement has not been verified/confirmed? North Shore Medical Center's Protocol, Procedure and Structure Standard all require this?  "Probably" is not good and PICC should not have been used.  Why not get a repeat film or contrast???

Maureen Lawler CRNI

Clinical Leader Venous Access Team

Salem Hospital

North Shore Medical Center

Salem, Ma 01970

maureen lawler
If this was a CVC placed by

If this was a CVC placed by MD, IJ or Subclavian, the policy still requires that the tip be verified in the SVC prior to use.

Maureen Lawler CRNI

Clinical Leader Venous Access Team

Salem Hospital

North Shore Medical Center

Salem, Ma 01970

Gwen Irwin
I don't usualy think that an

I don't usualy think that an xray is need for treatment of lack of blood return from any CVC. 

I reviewed what you say and wonder about the placement being "probably in proximal svc".  Triple lumen non-tunneled catheters have staggered lumens.  You stated that the proximal and medial ports were treated with tPA.  Therefore, the distal port might have been in the SVC.

I think that the tip (distal lumen) might have been in the upper SVC and the medial lumen and the proximal lumen were not in the SVC.  If tPA was given via the medial and proximal lumen, the dose was not given in the venous access system of this patient.  Therefore, the tPA might been given in the subQ, resulting in the ecchymosis that you observed.

Hope that this makes sense.

Gwen Irwin

Austin, Texas

smarison
We always get confirmation
We always get confirmation before use also.   Although with TPA, my understanding was it lies in the lumen of the Picc, therefore not entering the system at all.  I wonder how the ecchymotic area would have anything to do with that.  Confused???  I am interested in anyone elses thoughts.  Susan
afruitloop
I would like to add to one

I would like to add to one of the comments below. 

It was stated that if the distal was in the proximal SVC, the other two lumen exit holes may be in the subcutaneous tract.  Triple lumen central catheters cannot have the medial and proximal lumen outside the SVC and the distal lumen iniside the SVC.  In order for the tPa to infiltrate or extravasate, one of two things must occur..... 1) The catheter is extraluminal or 2) the catheter is encapsulated with a fibirn sheath or sleeve and the drug, in this case tPa, has traveled out the exit hole of the catheter, traveled down the lumen of the PICC and exited at the site of venous cannulation.

Keep in mind that high proximal SVC tips are problematic.  With a tip in this location, one must consider repeating the chest x-ray for signs of dysfunction as the catheter may have migrated out of position possibley to the left brachioicephalic vein.  Also, with a tip in this high postiion, perhaps it is abutting the wall of the SVC.  This is a more common likelihood with a left sided insertion that has a proximial tip, but it can be an occurrence with a right sided insertion.  Proximal tips can cause problems, thus should be avoided.

Good luck.

Cheryl Kelley RN BSN, VA-BC

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