webmm ahrq gov 197 slideshow by hFYQX75

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									Spotlight Case
Breakage of a PICC Line
              Source and Credits
    • This presentation is based on the April 2009
      AHRQ WebM&M Spotlight Case
       – See the full article at http://webmm.ahrq.gov
       – CME credit is available
    • Commentary by: Vesselin Dimov, MD
      Creighton University
       – Editor, AHRQ WebM&M: Robert Wachter, MD
       – Managing Editor: Erin Hartman, MS




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                        Objectives
        At the conclusion of this educational activity,
        participants should be able to:
    •   Appreciate the incidence and consequences of PICC
        line breakage
    •   Understand the risk factors for PICC line breakage
    •   Understand the treatment options in case of PICC line
        breakage
    •   Understand the measures to safely place a PICC line
        and prevent PICC line breakage
    •   Appreciate the guidelines to reduce risk of
        complications from central venous catheters


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          Case: PICC Line Breakage
    Born at 27 weeks’ gestation, a premature infant had a
    standard, silastic, 1.9 F percutaneously inserted
    central venous catheter (PICC) placed on day two of
    life for parenteral nutrition. The PICC was inserted
    under sterile conditions with placement verified by
    X-ray. Initially, the infant was on ventilator support
    and NPO due to feeding intolerance and necrotizing
    enterocolitis surveillance. Several attempts were
    made to introduce feeds; however, the infant
    continued to have large residuals and increased
    abdominal girth.

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        Case: PICC Line Breakage (2)
    After 40 days of parenteral therapy, the antecubital
    site and the upper arm became red, swollen, and
    tender to the touch. The neonatologist opted to
    remove the catheter. When the RN started to remove
    the PICC, it broke, leaving approximately 7 cm in the
    patient.




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        Case: PICC Line Breakage (3)
    After several attempts to retrieve the remainder of the
    line, with X-rays to check placement, the infant was
    sent for surgical removal of the catheter. Cultures
    taken via blood and PICC reported moderate growth
    of Staphylococcus. The infant required an increased
    level of care that included ventilator support, infusion
    of blood products, and antibiotic treatment.




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    PICC Lines Commonly Used Today
     • First introduced in 1975
        – Alternative to tunneled catheters or port lines
        – Now inserted under ultrasound or fluoroscopic
          guidance by interventional radiologists or PICC teams
     • Several attractive features
        – Easier, less expensive to insert than tunneled caths
        – Lower complication rates
     • Particularly attractive in neonates
        – May need fluid, frequent blood draws




7                                                       See Notes for references.
    PICCs Can Cause Complications
    • In retrospective series, complications
      included:
      –   Wound oozing and leakage
      –   Phlebitis
      –   Occlusion
      –   Infection
      –   Breakage
    • Complication rate ~5 per 1,000 catheter
      days
      – Complications usually in older (>30 days) PICCs



8                                                    See Notes for reference.
        PICC Breakage is Uncommon
    • One study: incidence ~ 7 per 1000 PICCs
    • Fractures associated with:
       – Older lines (only 2/11 broke < 2 months from insert)
       – Evidence of difficulty flushing line, leakage, blockage
    • Fractures not associated with:
       – Catheter size, insertion site, specific meds infused
    • All fractures near entrance site
    • Pathophysiology of break: probably mechanical fatigue
      and stress


9                                                           See Notes for reference.
            Discovery and Removal
     • Most fractures discovered by CXR or fluoro
       done pre-contrast injection
     • Removal: usually percutaneously
       – Fragment is snared, then pulled into sheath, which
         is removed
       – May be particularly challenging in neonates, as in
         this case



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       Why The Fracture in This Case
     • Small size of line (1.9F) in neonate
     • Line in place for more than 30 days
       – Likely develop fibrin binding of catheter
         to vessel wall, increasing chance of
         breakage on removal
     • Small syringe used for flushing
       creates higher pressure, increased
       stress on catheter

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     Recommendations for Prevention
     • Avoid flushing PICCs under high pressure or
       with small syringes
     • Remove PICC as soon as no longer needed
        – However, strict time limit not warranted presently
     • Ensure cath tip in large vessel (SVC)
        – Monitor frequently with CXR or ultrasound
     • Develop new PICC materials or coatings
     • Promptly investigate leaks, difficulty flushing

12                                                 See Notes for references.
                  Take-Home Points
     • Use of PICCs has become increasingly
       prevalent, including in pediatric inpatients
     • PICC complications include:
        – Injury to other vessels or organs during insertion
        – Catheter migration or malposition with extravasation
          from the malpositioned catheter
        – Infection
        – Thromboembolism
        – Catheter breakage
        – Dysfunction

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               Take-Home Points (2)
     • In a case series of 1650 PICCs, fracture and
       embolization occurred at an incidence of 6.7 in
       1000 PICCs
     • Duration of placement and line complication
       (blockage of the line or leaking at the insertion
       site) are associated with PICC fractures
     • Caregivers should be warned against flushing
       PICCs with small-volume syringes or with too
       much pressure

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