Twice within the last 2 months I have something happen that has never happened before. In the first case I placed a PICC in the brachial vein. The vein was to the side of the artery and a clear stick into it. Abotu time I got the drapes and needles cleaned up the site started bleeding and we could not stop it by holding pressure, pressure dressings, or surgicel. the line was removed due to bleeding. The chest xray showed the line in the SVC and the INR and PT and platelets were all normal. The patient did have a lot of tight edema in upper arm but it would still pit. This was the only vein in her arms that was large enough to access. Did not have other choices.

The second case was a brachial vein sitting on top of an artery. Again a clear stick with tip in SVC per xray. Line started bleeding and we were able to control bleeding with D-Stat but patient would start moving around and make it start to bleed again for 2 days. The D-Stat had to be reapplied several times. The brachial was the only vein available in this patient also. The patient also has edema in her arms with normal PT, INR, and platelets.

I don't know what happened and don't want it to happen again. Anyone have any suggestions other than avoid brachial which do whenever possible?

We do use Bard Power PICCs

We do use Bard Power PICCs with reverse taper. I rarely have bleedign but did on these 2 patients. We very infrequently have problems with DVTs that are clinically detectable. There may be clots but we see symptomactic DVTs in maybe 1% of patients.

One of the patients was on

One of the patients was on Arixtra.

Bleeding from PICC site related to Arixtra?

I have had this happen on perhaps 4 PICCs in the last 3 years. In all cases, the patient was on arixtra. In the worst 2 cases they were on arixtra, aspirin and either plavix or another drug of that type. Arixtra is the biggest culprit. It has a long half life and there is really no antidote for it, but of course it is much cheaper than lovenox. I think it is a dangerous drug. To control the bleeding, I have used a band from TZ medical 1-800-944-0187. It holds pressure on the spot but is not tight on the arm. Its just like someone standing there with their thumb on the spot. The worst patient had to have the band on for 2 days and the minute we took it off, it started bleeding. When we got it stopped for over 24 hours without the band, the doctor reordered the arixtra in the same dose. 1 day later, and 2 days after there was no bleeding, it started bleeding again just as bad. I would be interested in checking out the stop clotting product you mentioned if it works with arixtra on board. Do you know if your patient was on arixtra?

I agree with Lynn about the reverse taper not being a great thing for the vein as there definitely seems to be more DVT with these catheters. Also, since the taper on the Bard power PICC is 10 cm, that means some of the catheter has to be inserted into the vein directly throught the skin and not through the introducer. I think this is an infection risk and shorter tapers like the groshong are better, but I still am not sure they are great due to it being largest in the smallest part of the vein.

Michelle Todd, CRNI--Head PICC Nurse, Vibra Specialty Hospital of Portland somanysmiles@hotmail.com

It could have had an

It could have had an influence and other reason to include herbal products in our patient assessments. Gingko biloboa is known for prolonging clotting time and that is just one example of herbs that have an impact, 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

bleeding PICC

Hi Lynn,

This case is strange to me because since we have been using the reverse taper PICC lines, we have had little incidence of bleeding, even with INR's as high as 10. I was worried about bleeding with this patient so I performed a dilation , instead of a dermatotomy. After using Bioseal in this instance it convinced me that this product definetly will increase positive outcomes and we should use them on all of our central lines. Not just for the patients with higher risk of bleeding or with neutropenia. Just have to convince upper management. We started using the SV Power PICC from Bard about 3 months ago and since then have not had any incidence of upper extem DVT. We plan on using them alot more. Just a thought...someone mentioned to me that in the Asian culture , the people use a different variety of natural rememdies and herbs, and have a different kind of metabolism. Wonder if this had anything to do with her bruising and bleeding issues?       

                                         Cherylanne Perry RN,CRNI

                                         Nashua, NH

For those that have

For those that have experienced the site bleeding, are you using a PICC with a reverse taper or not? Theorectically this reverse taper is supposed to tamponade the puncture site and stop the bleeding but I have never been convinced that this was a good idea to put the largest size of catheter in the smallest portion of the vein. I was thinking about these dressing like Bioseal in comparion to the reverse taper just the other day and wondering how they would compare for clinical outcomes. 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

bleeding from PICC insertion site

Hello,

This same thing happened to me this weekend. Had a lovely Asian woman , normal platelets, started bleeding from her insertion site. I held pressure for 10 minutes and applied a pressure dressing. Of course I was called back to evaluate her and saw a SOAKING wet dressing! My first thought was OMG did I hit an artery? Blood was definetley venous, went back and checked my xray again and had the hospitalist check the patients cooags(whick all ended up normal). Luckily I have Bioseal. After 2 applications and a good 1/2 hour of continous pressure I finally got this site to stop bleeding. I really didn't want to pull this PICC, poor lady was covered with bruises from unsucsessful punctures in the ED. And (of course) was put on the worst vesicant IV abx. I just checked in on my lady today and her dressing remains dry , intact with no further bleeding. I reccomend this product and I wish I could use it on every PICC but nowadays we have to be cost effective. At least my facility lets me have them for special cases. One more thought: when you do use this product , make sure you inservice the staff nurses! Had one nurse see the dressing and call me in a panic thinking there was "stool" oozing from her insertion site!

                            Sincerely, Cherylanne Perry RN,CRNI

                                           IV Therapy Clinical Coordinator

                                          St. Joseph Hospital, Nashua NH          

 

bleeding from PICC insertion site

Hello,

This same thing happened to me this weekend. Had a lovely Asian woman , normal platelets, started bleeding from her insertion site. I held pressure for 10 minutes and applied a pressure dressing. Of course I was called back to evaluate her and saw a SOAKING wet dressing! My first thought was OMG did I hit an artery? Blood was definetley venous, went back and checked my xray again and had the hospitalist check the patients cooags(whick all ended up normal). Luckily I have Bioseal. After 2 applications and a good 1/2 hour of continous pressure I finally got this site to stop bleeding. I really didn't want to pull this PICC, poor lady was covered with bruises from unsucsessful punctures in the ED. And (of course) was put on the worst vesicant IV abx. I just checked in on my lady today and her dressing remains dry , intact with no further bleeding. I reccomend this product and I wish I could use it on every PICC but nowadays we have to be cost effective. At least my facility lets me have them for special cases. One more thought: when you do use this product , make sure you inservice the staff nurses! Had one nurse see the dressing and call me in a panic thinking there was "stool" oozing from her insertion site!

                            Sincerely, Cherylanne Perry RN,CRNI

                                           IV Therapy Clinical Coordinator

                                          St. Joseph Hospital, Nashua NH          

 

I could have hit some small

I could have hit some small vessel, I just don't know. I went years without this happening and don't want it to happen again. I am starting to get a complex!

We are trying to get some

We are trying to get some BioSeal in. We did use D-Stat on the second on with fair results if the patient would stay still but you had to hold her arm to keep her still.

 Its easy to focus on the

 Its easy to focus on the major vessels but if you've ever seen a surgery there are many small "spurters" throughout a procedure.  Placing PICCs is essentially a small surgery since we go thru tissue to reach the basilic/brachial but we can't cauterize any small vessels we hit.  We aim for the basilic with US, seal all of our piccs at insertion and have basically eliminated site complications.

I think anything is possible

I think anything is possible including the passage of the needle through a perforating vein or pressure from the edema and pulsation of the artery against the vein with the puncture and presence of the PICC. I wonder if it would have stopped with some of the new thrombotic dressing products now available for PICC sites. 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

Is it possile you punctured a

Is it possile you punctured a perferator vein that either looked like part of the facial plane because it was imaged longitudinally or was outside the probe's footprint distal and superficial to the brachial vein you were targeting?

Daniel Juckette RN, CCRN, VA-BC

These were both deep veins.

These were both deep veins. We did check blood gases form line and it was venous. Both lines had a steady trickle of blood from the exit site. It is kind of scarey since I don't know what was going on and don't want to repeat it. The sticks were clean and no trouble getting dilator in. Do you thing that with the edema squeezing the arm and the veins touching the artery that the pulsations of the artery against the vein could have caused the continued bleeding?

The brachial veins are not

The brachial veins are not superficial. In fact they are considered to be deep veins located in a protective sheath with the brachial artery and nerves under the muscles. So I think the dermotomy idea would be unlikely even with a small arm. The brachial artery could still have been damaged with the needle, although unlikely if this was US guided. Did the volume of bleeding change in any way based on the position of the arm? I am wondering about how the catheter in the vein might have caused some enlargement of the puncture site based on position, tension due to how the catheter is stabilized etc. Do you think this was arterial or venous blood based on appearance or volume? Usually continued bleeding is more of a slow oozing rather than frank bleeding. I think avoiding the brachial is always a good idea if at all possible. They are smaller in diameter, close to nerves and arteries and seem to have more problems. But if there is nothing else, you are caught between a rock and a hard place. So you have to decide if a PICC is even the best thing for that patient or if another type of catheter would be better - the old risk vs benefits thing again. 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

If the vein is superficial,

If the vein is superficial, it is possible that the artery was nicked during the dermatotomy. If possible, I avoid the dermatotomy with brachial placements.

Daniel Juckette RN, CCRN, VA-BC