6 year-old male well-nourished patient receives IV fluids nightly with D10 ½ normal saline 1000 ml over 12 hours. Mother pages on-call provider concerned that Broviac might have come out 3 cm. Patient is asymptomatic. Next visit is scheduled for 1 week.
What is the next step?
A. Reassurance and check X-ray at next visit. Consider scheduling outpatient Broviac re-wiring if needed.
B. Emergency referral to surgery for central line replacement
C. Change IV fluids to normal saline due to danger of hyperosmolarity.
D. Stop IV fluids.
E. Order Tissue plasminogen activator (tPA)
The correct answer is a. Reassurance and check X-ray at next visit. Consider scheduling outpatient Broviac re-wiring if needed. The osmolarity of Dextrose 100 grams/L X 5 + Na 77 X 2 meq/L is 654 mOsm/L, which is below the maximum osmolarity for a peripheral vascular (900-1000 mOsm/L). Several factors including suboptimal tip location, patient, infusion solution are known to increase risk of phlebitis, thrombosis, thrombophlebitis, infiltration, and extravasation when infusing high osmolarity solution. Warning: If a PICC is retracted, it is a good idea to check a chest X-ray right away. PICCs are sometimes stiff and if the tip is perpendicular to the blood vessel wall, they can cause a devastating vascular perforation.
ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines
for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002 Jan-Feb;26(1 Suppl):1SA-138SA. Erratum in: JPEN J Parenter Enteral Nutr 2002 Mar-Apr;26(2):144. PubMed PMID: 11841046.
Tager IB, Ginsberg MB, Ellis SE, Walsh NE, Dupont I, Simchen E, Faich GA. An
epidemiologic study of the risks associated with peripheral intravenous
catheters. Am J Epidemiol. 1983 Dec;118(6):839-51. PubMed PMID: 6650485.