One of the great things about this venue is learning from each other
and sharing experiences, so here goes.
Situation:
1. Patient with dx of cellulitis left thumb.. mri negative for
osteo... treatment for 3 weeks of IV vanco. (p.s. patient is ARNP,
midwife OB/GYN with years of OR expericene).
2. PICC nurse 14 years experience (last 4 with MST and US) using
same style of equipment for 2 years and does not perform the through
the back wall technique of needle insertion .
Procedure: Bedside PICC placement.
1. Patient, along with the nurse, observing real-time ultrasound
guidance with 21 ga needle into vessel with free flowing blood return
(right basilic vein size of a dime). Needle easily visualized on the
screen and into vessel. Upon advancement of nitinol wire, stated
"now I feel that". Wire was GENTLY retracted without difficulty,
established 3 ml of blood return via a syringe(good drip throughout
procedure) and wire was gently advanced but at 7 cm again stated
"feel that again". Denied sharp, tingling, etc. but just "funny".
Immediately removed the needle from the site, engaging the safety
feature, then started retracting on the wire which became stuck.
(past cases)
a. On 3 separate occasions with PICC placements over the last 2
years, while utilizing fluro, I have visualized the wire kink, coil,
etc. Advancement of the dilator sheath over the wire allowed the
wire to be removed successfully without trauma (except to the nurse,
me!).
2. Unable to pass the sheath (gently) on 2 attempts and I stopped
and called Radiology. (Did I mention that this was for discharge and
that it was 4 PM?) Arm was wrapped and the patient was transported
in her bed to specials.
Action: (short version)
1. Diagnostic Radiologist started the fluro to determine what was
going on. NO coil, kink was present but there was a small backwards
C to the path of the wire. Measured 4 cm of wire that was inside the
skin. (Now the vein visualized on the ultrasound screen between 1/2
and 1 cm depth). He pulled on the wire and the patient came off the
table.
2. IR was called in and the reaction was duplicated x 2 when he
stopped.
3. Wire was coiled outside the skin, tape applied and tegaderm to
maintain sterile area.
4. Transported back to room and attending MD called, with orders to
obtain "urgent" vascular consult.
5. Vascular surgeon arrived, held discharge, put her on the OR
schedule for the next day.
His intent was to "yank it out" (I was present when he told her his
plan of action ...done it many times, doesn't hurt a thing).
Result:
1. Surgeon reported to me:
a. He was glad that when the dressing was removed and site
prepared, that he broke the nitinol wire. He had about 10-12 cm to
work with. Because by the wire breaking he had to change his plan.
Fluro was used, the skin opened, and the vein exposed. "Never saw
anything like it!"
b. The soft end of the nitinol wire had punctured thru the vein and
wrapped around the nerve. He was able to release the wire. Said no
thrombus formation started, vein looked good, etc.
c. She did not demonstrate any nerve damage or numbness to her
fingers with good ROM.
Good luck guys!
Shirley
