Good morning!
Please help because I can't figure this out! I was called to CCU to assess a new PICC that will not infuse or aspirate. The patinet has pulmonary embolism and S/P IVC filter and on a heparin drip. She also has a h/o PVD, DVT and bariatirc surgery. It's a right sided dual lumen power injectable PICC, inserted in the brachial vein using ultrasound. It wsa placed in the IR by me and tip placement in SVC read by radiologist. Patient's creatinine level is up due to contrast from CT scan of chest per renal consult.
I changed the dressing and found no kink in the external PICC (1cm out). I TPA'd both lumens and after 2 hours of dwell time, both lumens were still occluded. The arm is not swollen. The nurses said that the IV pump they're using was working properly so I can't blame the pump either. They also denied drawing blood from the PICC as it's being used for heparin drip.
So what do you think is happening here? One radiologist that I consulted just want to change it to a new PICC!
Thanks in advance for all the response. Have a nice day1
You said this PICC would not infuse or aspirate yet fluid is flowing with a pump? Do you mean infuse by gravity? I would request a dye injection under fluoroscopy to see the actual fluid pathway. This could be some aberrent venous pathway that is creating a kinked catheter and gravity does not produce enough infusion pressure thus requiring the much greater pressure from a pump to overcome the resistance. Also, look at exactly what fluids and meds have been given through this line, if the correct saline flushing was done in between meds to rule out drug incompatibility, although this is not likely the problem if both lumens wil not infuse by gravity. Where in the SVC is the tip location? CAJ or higher? Was a lateral xray done to rule out azygous vein location? Could be several mechanical issues. Lynn
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
Lynn, the infusions thru both lumens were all via pump. It was running fine throughout 11-7 shift. In a.m., however, I was told that the pupms were going off " occlusion patient side" and when they checked, they would not flush nor aspirate.
The location is distal SVC. The radiologist that I initially consulted did not want to do any further x-ray---he just wanted to change it altogether.
I consulted another radiologist ( I work with 4 of them) this morning and this one thinks that the patient given her history, has hypercoagulabilty problem and therefore he thinks that even the new PICC will eventually clot off.
You can try a second dose of CathFlo as an extra 14% open according to studies after 2 doses and four hours
This might be a chemical occlusion but having both lumens occluded leads one to believe it is fibrin based
This could be a mural thrombosis as well and you can contact medical services at Genentech to discuss solutions
Exchange over a wire is an option but as Lynn Hadaway points out a dye study prior to exchange will likely bear some new information. Exchange takes a catheter from the dirty sock and puts the new catheter into the same dirty sock. Just a thought
Kathy Kokotis RN BS MBA and I am biased as I do speaking for Genetech
Bard Access Systems
We just did a catheter exchange on this patient, but before we started, we took an initial film and found that tip was in the right IJ. The radiologist then exchanged it for a new PICC, 3cm longer, so the tip is now in cavoatrial junction. The old tip placement must not have been distal SVC, it must have been proximal SVC. Anyway, the patient admitted to coughing a lot sometime that morning. So the mystery is solved: a malpositioned PICC.
Hi,
I know this is a little late, but at my facility we do CXR prior to cathflow insertion to ensure tip position. I noticed that this does not seem to be a requirement. I also noted that INS guidelines do not say anything about this. Is there a reason why a CXR would should not be prior to other interventions?
Shana
Shana Taylor, RN, BScN, MN:ANP, NP
Clinical Educator
Vascular Access Services, Colposcopy, Cystoscopy, Endoscopy,
Medical Outpatient Procedures,
It depends on the approach and/or thoughts at each facility. Some think that a malpositioned catheter tip should be ruled out before using the Cathflo, and thus a chest xray would tell you about the catheter tip location. But this is all that it would tell you. Some will use a thrombolytic agent before any other radiographic diagnostics to see if the Cathflo works. I am not aware of any studies showing that one approach is better or worse than the other. Others will require a contrast injection under fluoroscopy before anything is infused or injected into the catheter to determine fluid flow pathway. Lynn
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