PICC changed to Internal Jugular on Dialysis Patient – Nurse Clinicians in Action – 55

PICC changed to Internal Jugular on Dialysis Patient describes an Emergency Department patient with chronic heart failure and renal disease who was prescribed a PICC line for administration of Milrinone, but the patient’s comorbidities made this a challenging and complex vascular access placement case.

PICC changed to Internal Jugular on Dialysis Patient

– Clinical Case

*NOTE: At the time of this patient case, the facility had not added tunneled central lines – which also could have been an option for this patient – to their services contract with Vascular Wellness; since then, they have added tunneled central lines and have utilized this service to speed access to treatments for their patients.

A middle-aged dialysis patient with congestive heart failure and an EF (ejection fraction) of around 20% (indicating a very serious condition) was in the Emergency Department of a hospital. The patient had what might have been a tunneled powerline on the left side that was placed at another facility by their physicians, but it had come out, resulting in the trip to the Emergency Department. Additionally, he had an infected wound that was being treated.

Because of his congestive heart failure, the patient needed vascular access for the administration of Milrinone, a strong medication that is prescribed for patients with issues like chronic heart failure, as in this case. The care team contacted Vascular Wellness and ordered a PICC line to be placed in the patient.

PICC changed to Internal Jugular on Dialysis Patient

– Diagnosis and Treatment

The Vascular Access advanced trained vascular access nurse clinician (ie, trained in CVC placement) arrived at the hospital’s Emergency Department a short while later and began her patient assessment. She noted that the patient had a Permcath (a Large Bore Tunneled Central Line that is placed in the upper chest area and is used for hemodialysis for patients with kidney failure) in the right Internal Jugular vein.

Because Milrinone has a low pH and needs to be administered via a continuous drip, a PICC line (peripherally inserted central line or catheter) was ordered to reduce the risk of vein irritation and extravasation (leakage into the surrounding tissues that can cause permanent tissue or nerve damage), and Nephrology approved the vascular access line.

Knowing that special consideration must be given for patients with renal disease, including vein preservation for possible future needs for fistula sites, the Vascular Wellness vascular access nurse clinician consulted with the Emergency Department physician. She explained the importance of avoiding the arms whenever possible, especially given the patient’s young age, and recommended changing the order to a Small Bore Internal Jugular (IJ) central line.

The physician hesitated, worrying that treatment would be delayed significantly while they waited for availability in an Operating Room or Interventional Radiology to perform the procedure. The Vascular Wellness nurse clinician explained that she could place the Small Bore Internal Jugular central line during that same visit, right away, and the physician was relieved.

The vascular access order was changed by the physician to the more clinically appropriate Internal Jugular central line, and the nurse began her physical assessment of the patient’s vasculature with her ultrasound. Because the patient had a Permcath on the right side, she determined the left side was best and began the procedure. Once she accessed the vein and placed the introducer, she began attempting to place the Internal Jugular CVC (central venous catheter).

Despite the vascular access clinician being deeply trained and having extensive experience, she had some difficulty getting the catheter past the Permcath from the left side. She obtained an X-ray and noted that the catheter took a path down an accessory vein rather than going into the SVC (superior vena cava). She immediately informed the patient and his family, and they discussed his options.

If the vascular access nurse clinician was unable to place the IJ at the bedside, the patient would need to be transported to Interventional Radiology at a hospital over 2 hours away for placement of a Tunneled Catheter (*See note above). She explained to the patient and family that she felt confident she could place the line, but ultimately it was their decision. After discussing with his family, the patient decided he wanted the Vascular Wellness nurse clinician to attempt to place the IJ on the right side.

The vascular access nurse clinician accessed his right IJ and again had some difficulty getting the catheter to get past the dialysis catheter and into the SVC. She continued working on advancing the catheter slowly, utilizing her troubleshooting skills and patience, and eventually was able to get the catheter properly seated in the SVC. The vascular access nurse clinician obtained another chest X-ray to confirm its position, and it confirmed a successful placement of an IJ on the right side.

The patient and his family were so happy to be able to avoid the trip to another hospital. Additionally, the patient, his wife, the X-ray techs, and the vascular access nurse clinician high-fived each other once the X-ray was complete!

This was a lengthy case that kept the nurse out very late, but she was thrilled to be able to help this patient and provide exceptional client and patient service, a hallmark of Vascular Wellness. She said, “It was very rewarding to be able to get this patient the access that he needed and help him and his family avoid a trip to another hospital several hours away.“

PICC changed to Internal Jugular on Dialysis Patient – Vascular Access Specialists

– Key Points

With Vascular Wellness, clients (and their medical care teams) know that they get the benefit of the most innovative and up-to-date procedures and best practices that are unmatched in the industry. It means more than just having skilled vascular access nurse experts travel to the patient’s bedside to place requested lines when needed. It means clients have a vascular access partner that provides the most comprehensive, timely, and highest quality vascular access services they can rely on for:

Patient-Centric Vascular Access: Our patient- and client-centered team of Vascular Access Board Certified (VA-BC) and skill-verified specialists work with clients to ensure the best, safest, and most anatomically appropriate and comfortable access for their patients right at their bedside when they need it.

Reduced Risk of Infections: Two key ways to reduce the risk of infection include ensuring successful vascular access (we support a >98% success rate on both Standard Lines such as PICCs, Midlines and PIVs, and Advanced Central Lines such as Small and Large Bore Central Lines, including Dialysis Catheters and Tunneled Central Lines), and by eliminating unnecessary exposure to germs by removing the need for transportation to the OR or IR Department in another hospital, or within the same facility.

24/7/365 Access at No Charge: No matter the time of day, our clients have access – at no charge – to our VST (Vascular Support Team Client Call Center) and on-call advanced vascular access clinicians to ask questions, collaborate, troubleshoot, schedule procedures in advance, and during on-site business hours, request services.

Vascular Wellness is the smart and safe choice for Vascular Access for all healthcare settings. When it comes to Vascular Access at the Bedside – One Call Truly Does it All.

Nurse Clinicians in Action is a spotlight series highlighting some of the interesting cases that Vascular Wellness clinicians have encountered and participated in treatment. These cases involve challenging situations or intriguing clinical presentations and may involve more than one Vascular Wellness clinician, as our clinicians have the ability to consult each other while in the field, as well as an on-call Clinical Administrator via a HIPAA (Health Insurance Portability and Accountability) compliant communication app. In addition, our extensive training program and diverse client base, including Level 1 Trauma Centers, Short Term Acute Care Hospitals, Long Term Acute Care Hospitals, and Skilled Nursing Facilities, provide our clinicians with a wide array of clinical experience and why we believe our clinicians, as a group, are the most experienced and best trained and supported vascular access clinicians.

If you require Vascular Access or want to learn more, speak to the team at Vascular Wellness today.
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Vascular Wellness provides:
(1) Comprehensive vascular access services to North Carolina, Oklahoma, South Carolina, and Virginia; and
(2) Customized vascular access services to Arkansas, Delaware, Georgia, Mississippi, Pennsylvania, Tennessee, and West Virginia; and
(3) Support vascular access services to Ohio and Kentucky.