SPONTANEOUS CATHETER MALPOSITIONING: A CASE REPORT

Abstract

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Peripherally inserted central catheter (PICC) usage has increased significantly since introduction in the late 1970s. Growing bodies of evidence demonstrate the safety and efficacy of PICCs for treatment regimens up to 6 months in the outpatient setting, but PICCs can have complications. We described a patient with spontaneous repositioning of his PICC line tip with subsequent resolution. CASE PRESENTATION: A 39-year old man with an extensive past medical history presented to a referring hospital for sudden onset, severe abdominal pain, and new associated shortness of breath. On hospital day (HD) 3, a PICC was placed in his right upper extremity with the tip overlying the cavoatrial junction. A CT chest on HD8 demonstrated a change: the tip of the PICC had reversed course and flipped from the SVC into the ipsilateral internal jugular vein. The PICC flushed appropriately and drew briskly. Our medical center’s dedicated peripheral access team power-flushed the catheter a total of three times. The patient reported that he heard the first flush in his right ear, but did not hear the subsequent second nor third flushes. A repeat chest XR demonstrated an interval flip in the direction of the PICC with the tip appropriately at the junction of the right brachiocephalic vein and the superior vena cava. This PICC flipped once more before removal before discharge. DISCUSSION: Although studies have been performed examining rates of inappropriate positioning after initial PICC placement, limited data exist regarding rates of spontaneous malpositioning of PICC tips. Subsequently, no societal guidelines exist for PICC placement monitoring in a patient receiving extended therapy intravenous medication delivery. Our medical center’s policy states that all forms of existing central access in the upper extremity or trunk are verified using chest XR or other imaging upon patient presentation to the emergency department or admission to a hospital before usage. When PICC tips are noted to be inappropriately positioned, there exists data to support both a trial of observation for spontaneous repositioning (especially if the catheter edge is in the ipsilateral internal jugular vein or contralateral subclavian vein) and immediate intervention or manual repositioning. CONCLUSIONS: Given that our patient’s PICC spontaneously repositioned twice during 13 hospital days and the morbidity that inappropriately positioned peripheral catheters can cause, it may be reasonable to obtain a routine chest XR to verify PICC positioning every 1 to 2 weeks for both hospitalized and ambulatory care patients. When PICCs spontaneously malposition, we support decision making on a case-by-case basis, depending on the patient’s acuity, associated symptoms, the ability of the catheter to draw/flush appropriately, availability of other intravenous access, and remaining anticipated required length of central access. Reference #1: King MM, Rasnake MS, Rodriguez RG, Riley NJ, Stamm JA. Peripherally inserted central venous catheter–associated thrombosis: retrospective analysis of clinical risk factors in adult patients. South Med J. 2006;99(10):1073–1077 Reference #2: Chen W, He L, Yue L, Park M, Deng H.: Spontaneous correction of misplaced peripherally inserted central catheters. Int J Cardiovasc Imaging. 2018 Jul;34(7):1005-1008. doi: 10.1007/s10554-018-1321-5. Reference #3: Campagna S, Et Al.: A retrospective study of the safety of over 100,000 peripherally-inserted central catheters days for parenteral supportive treatments. Res Nurs Health. 2019 Jun;42(3):198-204. DISCLOSURES: No relevant relationships by Christian Ghattas, source=Web Response No relevant relationships by Divyesh Mehta, source=Web Response No relevant relationships by Virgil Secasanu, source=Web Response