Recurrent Ventricular Dysrhythmias Following Placement of a Peripherally Inserted Central Catheter Using Intracavitary ECG Guidance

Abstract

SESSION TITLE: Fellow Case Report Poster - Critical Care III SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Peripherally inserted central catheter (PICC) placement using anthropometric measurements is inaccurate, with malpositioning rates of up to 76%. In contrast, intracavitary electrocardiogram (ECG) guidance achieves a malpositioning rate of 0-21% with no reported complications.1-2 Nevertheless, adverse events with PICC insertion using intracavitary ECG guidance may be under-reported. We describe a case of PICC insertion using the Sherlock 3CG TCS® that resulted in catheter tip malpositioning in the deep right atrium, leading to recurrent ventricular dysrhythmias. CASE PRESENTATION: A 56 year-old man without prior cardiac history underwent PICC placement for venous access by the PICC team, which has used the Sherlock 3CG TCS® since 2014 and places an average of 1350 PICCs per year. A 5-French double-lumen PICC was introduced into the right brachial vein under ultrasound guidance and was advanced 43 centimeters with confirmation in the superior vena cava. Over the next 2 hours, the patient experienced 8 episodes of self-resolving ventricular tachycardia but remained asymptomatic. ECG and electrolytes were normal. Serial troponins were negative. Over the next two days, the patient experienced repeated episodes of non-sustained ventricular tachycardia (Figure 1). Echocardiogram identified a linear echodensity at the tricuspid annulus (Figure 2). The chest radiograph demonstrated the catheter tip in the deep right atrium. The PICC was retracted 4 centimeters with immediate and sustained resolution of the dysrhythmias. DISCUSSION: PICC insertion using intracavitary ECG guidance may carry a higher risk of adverse events than is currently reported. Indeed, atrial and ventricular dysrhythmias are documented after PICC placement using conventional anthropometric measurement techniques. Clinicians should be aware that similar events may occur with ECG-guided techniques. CONCLUSIONS: This case demonstrates the potential for dysrhythmias following PICC insertion using intracavitary ECG guidance, a previously unreported event. Reference #1: Johnston AJ, Holder A, Bishop SM, See TC, Streater CT. Evaluation of the Sherlock 3CG Tip Confirmation System on peripherally inserted central catheter malposition rates. Anaesthesia. Dec 2014;69(12):1322-1330. Reference #2: Pittiruti M, Bertollo D, Briglia E, Buononato M, Capozzoli G, De Simone L, La Greca A, Pelagatti C, Sette P. The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study. The Journal of Vascular Access. Jul-Sep 2012;13(3):357-365. DISCLOSURE: The following authors have nothing to disclose: Jennifer Cabot, Caroline Shirzadi, Louis Voigt, Stephen Pastores, Neil Halpern No Product/Research Disclosure Information