Eeesh...what was that?

[Sassafras]

Patient last night had picc line in one arm, other arm swollen and discolored. I say something about "I guess we're getting the thigh cuff out" and was directed by hospital staff that doctor indicated picc line arm was to be used. :wacko: Patient says no one has used a thigh cuff in months. In long term rehab hosp going to actual hospital for nuclear scans. I'm gonna have her for a while. I told her I'd be willing to try the arm w/ the picc line but if things looked the slightest bit odd I was going to have to use the thigh cuff on her. And I was VERY careful so as not to disturb things. I checked the swollen arm though and felt I may kill the poor thing if I squeezed it at all. Bruised all over, up and down with scarring and scabs from dialysis. Lightly grazing the bruises with the pads of my fingers you could feel the blood coursing through bounding so hard it felt like electric pulses. I was having flash backs of a Dr. G medical examiner episode where the guy's dialysis blood vessels burst open and he bled out in minutes.

Never seen anything like it. I feel much more confident in brachial or palpated pulses than thigh. Only ever reviewed in EMT class, never practiced, never tested on it. Only ever done once. I still wonder if it was the right move, but patient was lucid and we have been taught to listen to our patients so I tried it. I was able to avoid putting the cuff on the entrance site. She never complained of pain and I told her if it even felt slightly weird to tell me. It did work, but not sure I'm comfortable doing it. Then I got to thinking later, "they are all telling me it's a picc line, but aren't those into the upper chest?" this was on the distal side of her arm, right above the elbow (opposite where you would put the stethoscope), with a spider of tiny tubes coming out...I'm wondering if it's a different type of IV...dunno...I shall leave the education of my mind to you more knowledgeable types.

Question is...the swollen arm...was there a risk there? Or was I being over paranoid?

 

[Hockey]

Never did a thigh. Heck, I don't even know if I know how

 

[Amycus]

As a general rule of thumb, if I'm on an IFT truck at the PT is AOxwhatever, I'll simply ask them "Which arm is it best to take a BP on?" and have them make the decision for me. Alternatively, if they are being discharged, it can be nice to ask the RN if there are any precautions you should know about, including which arm to not use.

As a rule of thumb I won't take them on an arm with a picc line out of fear I'll damage it. Same logic with shunts and such. That arm is off limits to me. The swelling I can't speak to because I don't know what caused it, but my guess is the swelling could cause you to need to use a different sized cuff, possibly giving you an inaccurate reading.

I've done a forearm a couple times now. Just slap it on their forearm and grab a quick one by palp. Worked pretty well for those quick and dirty situations.

Edit 2: Oh, and as far as I'm aware, those spiders of tubes in an arm are a picc line. That's how I've always been taught anyways.

 

[Veneficus]

Patient last night had picc line in one arm, other arm swollen and discolored. I say something about "I guess we're getting the thigh cuff out" and was directed by hospital staff that doctor indicated picc line arm was to be used.

It is not outrageous to use the same arm as a PICC. It is just not the preferred choice if the opposite limb is available.

In a bed confined pt, a thigh cuff might be a greater evil than using the same limb as a PICC as it could dislodge potential clots. (they usually stop in the pulmonary artery)

I told her I'd be willing to try the arm w/ the picc line but if things looked the slightest bit odd

If the nursing staff has been doing it for a month, I wouldn't worry too much.

I checked the swollen arm though and felt I may kill the poor thing if I squeezed it at all. Bruised all over, up and down with scarring and scabs from dialysis.

Probably not a good idea to use that one.

Lightly grazing the bruises with the pads of my fingers you could feel the blood coursing through bounding so hard it felt like electric pulses. I was having flash backs of a Dr. G medical examiner episode where the guy's dialysis blood vessels burst open and he bled out in minutes.

I think it would make the transport more exciting though

Never seen anything like it.

Isn't that the best part of medicine?

"they are all telling me it's a picc line, but aren't those into the upper chest?"

They can be put into any peripheral vein, but the Basillic and subclavian have the most direct route to the SVC.

The Subclavian though has a higher rate of infection and a higher complication rate. So it is not the best choice.

this was on the distal side of her arm, right above the elbow (opposite where you would put the stethoscope), with a spider of tiny tubes coming out...I'm wondering if it's a different type of IV...dunno...

Sounds like somebody put it in the cephalic vein, that will end in the same place. You can connect a bunch of lines to any port by either starting with a multiport/multilumen catheter or a network of adaptors.

Question is...the swollen arm...was there a risk there? Or was I being over paranoid?

There is always a risk, but that is different from impending doom. Sounds like you were more worried about it than everyone else.

 

[Sassafras]

Well, I was told not to use that arm by patient and staff due to the swelling, and on feeling the pulsations (stronger than a carotid pulse) I asked the nursing staff if they were aware on return and they all acted shocked and thanked me for informing them.

And thanks for the point by point vene...I guess I did ask a lot o' questions there. Something new to learn every day LOL.

 

[8jimi8]

PICC line stand for Peripherally Inserted Central Catheter. While it is best not to take a bp over a picc line, i've never seen anything bad come of it, never heard of anything bad coming of it either, although, I supposed if you tugged on it hard enough, you would see some pvcs on the monitor. The pulsations you felt on the swollen arm was most likely the thrill and if you put your stethoscope on it, you will hear the bruit.

you could also check the bp on the forearm, just make sure to document where you took the pressure and it doesnt matter where you take it. As Vene said, you made a good choice not to take the bp on an extremity with dialysis access. You should never start IVs or draw blood off of an extremity with dialysis access.

And further, often PICC lines are contraindicated in anyone who is dialysis dependent. Usually the nephrologist will want to preserve the blood vessels in the upper extremities in case the patient must have another dialysis access made.

and the spider of tubes was either a "double" or "triple" multi-lumen PICC. I've never seen more than 3 on a PICC, but i suppose that could exist. The tip of the PICC line has multiple openings so that you can run more than one fluid through the picc at the same time. These will usually be labeleld proximal, median, distal, if you look close enough on the cap. Usually they will also be different colors and may be labeled by gauge sizes. You can go on and on about PICC lines, but that is the basics of at least identifying what you are looking at.

 

[Sassafras]

And further, often PICC lines are contraindicated in anyone who is dialysis dependent. Usually the nephrologist will want to preserve the blood vessels in the upper extremities in case the patient must have another dialysis access made.

Really? We have several regulars in end stage renal failure we transport back and forth to dialysis with picc lines in place. One of our long term regulars has had it removed and replaced multiple times since I've started here on a few months ago...wow. You learn something new every day. I wonder what the difference is with them.

And I did not put the steth on the arm. It skeered me. LOL

 

[8jimi8]

If the dialysis access in the other extremity fails, the arm that has had chronic PICCs will most likely be a poor candidate for a shunt or fistula to be placed. They may end up having to use one of the lower extremities as the dialysis access.

 

[Sassafras]

Ohhhhh. Ever feel like the more you learn the stupider you feel? LOL

 

[Hockey]

Ohhhhh. Ever feel like the more you learn the stupider you feel? LOL

I guess so

 

[MasterIntubator]

Ahhh... memories.... There is nothing like a ruptured dialysis shunt. That is one momma that will bleed a person out quick. Learn as much as you can about these beautiful things, and whether or not your protocols will allow you to access them in emergencies. ( There are classes and in-services specifically for these caths for field providers, at least the hospital provides them for us ).

PICCs are normally in the upper arm, and can be multi-lumen. Here are some other names for you to look up, as they do come up often for us in the field ( Hickman, Groshong, Broviac, port a cath ) which are normally placed in the upper right chest. Port a caths are one of those not normally accessed in the field, as they require a special needle and special technique to access. We carry a couple huber's, but we have to present a good case in order access one.

How many times do I expect to access a PICC or Central line? Maybe 2-3 times a year... so not much. But its a good skill to know. If you are in it long enough, you will come across them.

 

[8jimi8]

oh important to remember to always use a 10cc syringe to access. Anything smaller can rupture the line.

 

[Sassafras]

hey now, pokey things are beyond my scope of practice. I don't access any of em...us B'ers only get to bandage and blow some air in your face.

Oh and crack a few ribs if you decide to die suddenly while trying to drag you away from the light.

 

[Aprz]

Ohhhhh. Ever feel like the more you learn the stupider you feel? LOL

That is so true!

 

[Aidey]

Well, I was told not to use that arm by patient and staff due to the swelling, and on feeling the pulsations (stronger than a carotid pulse) I asked the nursing staff if they were aware on return and they all acted shocked and thanked me for informing them.

And thanks for the point by point vene...I guess I did ask a lot o' questions there. Something new to learn every day LOL.

Oh boy....That actualy scares me a little that the nursing staff was shocked.

The swelling may or may not be an issue. Because the vasculature in their arm has been "re wired" some pts with dialysis fistulas or grafts get edema in their access arm. They may also have benign localized swelling around the access due to the trauma of the IV sticks. If the pt recently had revision surgery it will also be swollen. Many fistulas and grafts also protrude and look like large misshapen veins. The bruising again may or may not be an issue. Some bruising is pretty normal, and other people bruise a lot. The vast majority of patients are given heparin during their treatments, hence the increased bruising.

As for the pulsing, its called thrill and it is totally and completley normal. In fact if it isn't there that is a serious issue. Thrill MUST be doccumented before and after every dialysis treatment because lack of thrill can mean the access has clotted off, which is mega super bad. If the pt is in a nursing facility they should be checking for bruit and thrill in the pts access, especially if it is swollen! Bruit is auscultated over the site, it is the sound of the blood flow through the access.

I would always do a BP over a picc line before doing it over a dialysis access. I dont like angry nephrologists coming after me with pitchforks.

 

[Sassafras]

Yup they were surprised. Weird huh? I wasn't concerned with the bruising as much as the pulsating but glad to kn ow it's normal. I'm going to have to check my regular dialysis transport to see it it's there next time. She let's me poke and prod her inthe name of learning lol. This patient did state there was a fistula in that arm now that you mention it. Is this thrill related to the fistula or just a result of long term dialysis. Sorry if I'm asking too many questions. This is kind of fascinating even if the smells at the dialysis clinic make me want to hurl lol. Blood mixed with vinegar and other chemicals. It's a crazy
combo of odors.

 

[firetender]

Kind of on topic...

Long story short; unconscious male, diabetic needing 50 cc I.V. bolus sugar (per criteria at the time), unusually large antecubital vein, insert needle, press plunger in 1/2 way and vein E-X-P-A-N-D-S, I look for leaks, can't find any, decide to PRESS on the expansion, it contracts, inject remaining bolus, vein expands, I press it in. Patient immediately recovers.

Had no idea at the time but was later to find out the man, who was frequently on kidney dialysis, had Bovine veins grafted in to his antecubital regions! Ever seen that?

 

[Cawolf86]

Is this thrill related to the fistula or just a result of long term dialysis.

It is the result of the artificial anastomosis created to serve as IV access. The artery and vein are connected in some manner which creates rapid, turbulent blood flow - which we feel as thrill or hear as bruit. It is a similar sensation that you could hear/feel over a partially occluded superficial artery.

 

[MusicMedic]

It is the result of the artificial anastomosis created to serve as IV access. The artery and vein are connected in some manner which creates rapid, turbulent blood flow - which we feel as thrill or hear as bruit. It is a similar sensation that you could hear/feel over a partially occluded superficial artery.

the bruit kinda sounds like a Sloshing/whirling sound right?

now ive seen patients with both a Shunt on their forearm and a Quinn Catheter on their chest. why do they have both?

 

[Aidey]

Thrill is the name of the feeling of the blood flowing through a vessel, in this case the dialysis access. It is part of the nature of the access, and doesn't relate to how long the person has been on dialysis.

I'm on my phone, so this is an abbrevated explination.

"dialysis access" or just "access" is a catch all term for any type of fistula, graft or catheter. In the cases of grafts and fistulas a vein and artery are attached to each other surgically. Either directly (fistula) or by a plastic tube or animal vein (graft). In fistulas this causes the vein to expand and become "arteralized". Because veins have weaker walls, they expand under the pressure, forming the large access you can see and feel. The needles go directly into the vein in fistulas. In grafts since the artery and vein are connected indirectly the vein doesnt become as big. In grafts the needles go in the graft rather than in the vein.

In either case you can feel thrill and hear bruit. Thrill tends to be more pronounced in fistulas than in grafts. Fistulas also tend to be more obvious because the vein expands so much. An access can be put in the forearm or upper arm and also the upper leg. The upper arm is the most common, the vessels there are bigger and it is more out of the way. The lower arm is pretty common too. The upper leg is kind of a last ditch option.

Keep in mind that some dialysis patients have a "dead access" in one or both arms. these are accesses that failed for whatever reason. Sometimes you can do BPs over them, other times not, it is best to ask the pt.