Need advise on complicated case. Pt with (B) mastectomies who had 2 sentinel nodes removed on one side and one sentinel node removed on the other side. This patient had a port which got infected and had to be removed and now needs treatment for endocarditis. Medical team enquiring for best option. They are asking me to consider placing a PICC on the side where one one node was removed. Risky, but would this be our best option?
Any advise would be appreciated.
No great options so your choice comes down to the lesser of all evils. Choices would include:
1. PICC on side with only one node removal
2. Jugular inserted PICC with subq tunnel to avoid usual IJ issues
3. Tunneled cuffed catheter
4. implanted port
I would want to collaborate with surgeon and oncologists, weigh risk and benefits of each option and then choose the one with the least risk to the patient. Questions to ask include how far post-op is the patient, signs and symptoms of circulatory issues on either arm, need for ongoing oncology drugs or just antibiotics, risk for IJ placement, anticipated length of therapy, caregivers for catheter during dwell time, etc. 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
Depending on a variety of factors, would a midline also be an option? Is there an increased risk of colonization of a new central line if there is an existing infection. Would a midline be far enough from the site of infection to reduce that risk? From an oncology standpoint, usually when a patient has had lymph nodes removed from both arms, a discussion is had early on about which arm will be used for blood pressure venipuncture, etc., and it's usually the one with the least compromise to lymphatic circulation. Any thoughts on these ideas? Keith
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
I don't see a midline as being an option because there is still the risk of lymphedema. Colonization of a new CVAD from an existing infection is possible but way, way done the list of possible causes. I assumed the concern was about lymphedema and not CRBSI due to the endocarditis. If ABX have been started via a peripheral catheter, I would be much more concerned about lymphedema than BSI. 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
Thank you so much. Discussion was very helpful!
SOD
Our hospital system opts to place tunneled piccs in the chest for patients that arms are not a good option (mastectomym lymph node disection, renal patients, etc). Radiology has been doing this for a number of years now and this has been a great option.
As a home care agency, we will not remove the chest placed tunneled piccs in the home.
Karen Charnigo, MSN, RN, CRNI