Today I had a pt who has a PICC line have a TEE to rule out bacterial endocarditis. She has the picc line because of poor venous access, long term antibiotics for treatment of Klebsiella in urine and other infectious processes. She has been spiking temperatures and was treated a month or so ago for bacteremia as well.
Prior to the procedure the nurse told me the lines, double lumen, were sluggish blood return and occ trouble with infusion. I wanted to treat it with cathflo but was waiting till after the procedure so our timing didnt interfere with the procedure.
the procedure is done and the doctor says he saw what he thinks might be vegetation on the PICC line tip; approx .5 cm by .8cm on the tip. I told him I was seriously wondering if this could be a fibrin sheath because of the issues we were experiencing with the picc line. I was talking to him, a pleasant coopertive conversation :) wondering if there was a way to differentiate this as a fibrin sheath versus vegetation without removing the line. We thought about a dye study but thought that will only show the growth and the trailing up of contrast and not be able to specifically show what it is.
He wanted me to remove the line and place a new one. Makes perfect sense to me if we suspect the line is infected, but??? what if it is only fibrin? I contemplated treating with cathflo butthis is an issue I would be afraid to incase it was vegetation, or infection in the fibrin and I do cathflo and release septic emboli.
So......I asked if we could get blood cultures from the line and the peripherall site to do a time to posititivity study. I also did a cutlure of the cath tip. Prior blood cultures negatives. Picc has been in for 8 days.
I removed the line, it appeared normal, and nothing on the tip. Of course I realize any fibrin may have slid of in the process of removing the line. I have seen my share of sheaths on the exit site, or half in and half out of the exit site.
Do any of you have any input as to a way to have helped us decide if this was fibrin or vegetation? We certainly wanted to play it safe for the patient and not take any chances. Any body else with experience with this?
I really think as fast as the bodies make biofilm and then fibrin, we might see this on many patients. But....then we have done TEEs on other pts piccs and havent seen this but at the same time they havent had partial occlusions either.
Thanks in advance for your input in this. I wlill be watching for the culture results.
thanks Gina Ward R.N.,
"vegatation" simply means any type of abnormal outgrowth usually from a body part such as on a cardiac valve. What he actually saw could not be identified specifically with the TEE, thus the use of this catch-all word. I think this was probably both fibrin and biofilm, creating this nidus for infection. The organism can easily be introduced during insertion or infusion or could have seeded from another location such as the urinary tract infection. There is no way to know exactly what this "vegatation" actually was without lab tests of it and capturing it is the problem. Use of tPA would not have been recommended especially on a repetitive basis. The tPA would have only reached the infected fibrin located directly at the catheter tip, leaving the remainder on the extraluminal wall to regrow into more infected fibrin. So removal of this catheter was indicated. The question remains about how long to wait before inserting a new PICC. You do not want to insert a new PICC into the same area where there may be infected fibrin/thrombus attached to the vein wall or in the bloodstream. Many recommend waiting at least 2 days, some 3 days, but there are no specific guidelines on this issue yet. I do not think that tPA alone and allowing this PICC to remain in place would have been appropriate. 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
Since it was a rule out endocarditis and the infection was in the urinary systme to begin with I will be real interested in the culture resutls
I will bet a $20 that they are negative cultures of the catheter done via quantitative or qualitative analysis. The catheter tip culture is meaningless as it is contaminated when it is pulled out of the site and can really provide no inormation as all catheter tip cultures do
kathy