Author
Information
Desai
DV*, Karve N**, Gupta AS***.
(* First
Year Resident, ** Fourth
Year
Resident, *** Professor. Department of Obstetrics & Gynecology, Seth
G.S.Medical College & KEM Hospital, Mumbai, India.)
Abstract
Thrombosis
of deep neck veins is a rare complication associated with peripheral
vein catheterization albeit with a high risk of adverse outcome. We
report a case of internal jugular vein thrombosis in a severely
anemic patient with peripheral intravenous central
catheter
(PICC)
line
inserted
for monitoring central venous pressure.
Introduction
In
the year 1856 Virchow published the landmark study on the
etiopathogenesis of pulmonary thromboembolism, which later lead to
the consensus on the high risk factors for thrombosis in blood
vessels, now known as the Virchow’s Triad; namely-
hypercoagulablility, endothelial injury and hemodynamic changes.[1]
Obstetric
patients are privy to all three of these factors which subjects them
to a high risk of thrombosis throughout their antenatal and
postpartum period. Pregnancy itself is
a
hypercoagulable state, a natural mechanism to reduce the total blood
loss at the time of delivery. The shearing forces of the fetal head
over the pelvic tissues, often times causes pelvic vessel thrombosis
due to local trauma. Hyperdynamic circulatory changes, physiological
anemia of pregnancy and stasis of blood in lower limb veins adds to
the probability of thrombosis and subsequent embolism. Anemia causes
turbulence of blood flow in vessels and thus adds to the risk of
thrombosis. At our institute we cater to high-risk obstetric
patients, a large proportion of which are anemic. We report a case of
internal jugular vein thrombosis in a severely anemic patient with
peripheral intravenous catheter line inserted for monitoring central
venous pressure during
process of abortion.
Case
Report
A
32 year old gravida 4, para 3, living 3 with 15 weeks' twin gestation
came with threatened abortion and a history of vaginal bleeding for
the last 15 days. All her previous pregnancies were vaginal home
deliveries. She had no previous medical or surgical history
suggestive of any
risk
of hypercoagulability. On examination she had
severe pallor and tachycardia - pulse 100 bpm. the uterine size was
of 18 weeks of gestation. Blood mixed liquor was demonstrated to be
leaking from the cervical os. Ultrasonography showed twin live
gestation of 19+6 weeks and 19 weeks with anhydramnios. Laboratory
investigations showed Hb - 4.8 g/dl and normal DIC profile. She was
started on parenteral ceftriaxone, metronidazole and gentamicin.
Peripheral intravenous central catheter (PICC),
size 14-16 Fr was inserted
in the right median basal vein for central venous pressure (CVP)
monitoring after written and informed consent
by a trained resident doctor under full aseptic precautions.
There
was no difficulty in its insertion and it was performed in a single
attempt with free flow of blood from it. Ringer's lactate infusion
was slowly given initially. It was secured by two linen sutures and
strapped by an elastic adhesive tape. She
was then
transfused
2 units of packed red blood cells (PRBCs) under strict monitoring
on two consecutive days from the PICC.
In between the PICC was flushed with normal saline. No antibiotics or oxytocin infusion was administered from that PICC.
Decision
was taken for induction of abortion.
After written and informed consent, induction of abortion was done
with PGE1.
A tablet of 400 μg PGE1 was inserted vaginally every 4 hourly till a
total dose of 2000 μg was administered. As the internal os had
opened PGE1 was sequentially followed by infusion of oxytocin
20 IU in 500 ml Ringer’s lactate.
The patient
aborted on 3rd day after induction. Emergency check curettage was
done with 4th unit of PRBCs on flow.
Strict
monitoring of CVP was done via the PICC line. The
column moved well with inspiration and was not suggestive of any
partial or complete block of the PICC. The
patient complained of pain, swelling and difficulty in neck movements
30
hours after
the
check
curettage. She
never had fever. Prompt ultrasonography
(USG) with Doppler
of the neck
showed right internal jugular vein thrombosis extending from the
right retro-mandibular region till its
opening
into the right subclavian vein, a length of approximately 6 cm, the
left side being normal. Neck radiograph was within normal limits.
PICC
was then immediately removed on day 6 after insertion.
Hematologist
was
consulted
and the patient was started
on unfractionated
Heparin
5000 IU S.C. 6 hourly and warfarin 5 mg H.S. Warfarin dose was
adjusted with daily monitoring of INR and heparin was discontinued
when PT-INR was above 2. Thrombophilia evaluation was deferred for 6
weeks on the hematologist’s advice. Patient was discharged on
warfarin 7.5 mg H.S.
She was advised to
continue
it
for 6 months. The couple was counseled to use barrier contraception
and avoid pregnancy for 6 months.
Discussion
Internal
jugular vein thrombosis is a serious event with fatal outcome.[2]
PICC’s have become popular for patients requiring long term
intravenous therapy due to less catheter related serious
complications due to improvements in catheter designs (flexible
non-thrombogenic silicone catheter).[3]
Complications of the PICC include occlusion (7%), rupture (1.6%),
accidental withdrawal (2.4%), infection (2.4%), pulmonary embolism,
sepsis with septic emboli, and intracranial extension of thrombus.[4]
There is also a risk of cardiac perforation and arrhythmia
if tip of PICC gets advanced.[1]
Guideline
for Peripheral intravenous line insertion[5]
Only
competent staff should do the procedure. PICC line should be inserted
in an area where asepsis can be maintained. All sterile techniques
should be implemented with good record keeping and documentation.
Post procedure modified chest radiograph should be taken with
visualization of catheter along the total
arm
length
across the axillary and subclavian veins. Preferable
location of the tip of the PICC is in the distal 1/3rd
of the superior
vena cava (SVC)
near its entry into the right atrium. USG
guided insertions are recommended in case of difficult insertions.
Basilic vein (8 mm) is the most preferred vein as it is less
tortuous. Sterile transparent semi-permeable self adhesive dressings
should be used to prevent complications. The
syringe recommended to flush the PICC should be a 10 ml syringe as
smaller syringes used for flushing can generate a higher pressure
that can result in damage to the vessel wall. The last 1/2 ml of
flush solution should be under positive pressure to prevent the back
flow of blood from the catheter tip so as to prevent occlusion by
clot formation. Presence
of tachycardia, tachypnea, hypotension, pain, trismus, raised central
venous pressure should raise a suspicion of a complication related to
these PICC. Management consists of anticoagulants, dose optimization
with PT-INR monitoring, prophylactic parenteral antibiotics, Superior vena cava (SVC) filters in case of failure of medical line of management. Certain
precautions are recommended for insertion of the PICC line. Proper
indication, asepsis, use of local anesthesia and post procedure
radiography for confirmation of correct placement are desirable.
Regular flushing of the cap at the end of the line decreases tip site
infection. To prevent phlebitis, some clinicians add heparin and
hydrocortisone to the solution or nitroglycerine patch over the
catheter site. It is imperative that peripheral catheter sites be
inspected regularly and catheter sites changed if evidence of
phlebitis develops.
In
our case, the PICC was inserted by a trained resident doctor.
However, the PICC should have been removed immediately after the
check curettage or after the completion of the transfusion of the 4th PRBC as the patient did not need any further CVP monitoring.
Catheterization for prolonged duration can cause endothelial damage
of the vessel walls and initiate the formation of a thrombus. Proper
implementation of the guidelines, prompt removal when the need for
the PICC ceases and a high degree of suspicion of complications
should be followed by all clinicians who have patients requiring PICC
monitoring.
References
- Silver D, Vouyouka A. Management of venous thromboembolism. In Baker R J, Fischer JE (ed); Master of surgery ;4th edition; Philadelphia, Lippincott Williams & Wilkins, A Wolter Kluver, 2001; Volume 2; pg. 2199
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Schroeder RA, Barbeito A, Bar-Yosef S, Mark, JB. Cardiovascular monitoring. In Miller RD (ed); Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL. (Associate Editors). Miller's Anesthesia. 7th edition. Philadelphia, Churchill Livingstone,Elsevier; 2010; Volume 1, pg 1287-1289.
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Weissman C. Nutrition and Metabolic Control. In Miller RD (ed); Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL. (Associate Editors). Miller's Anesthesia.7th edition. Philadelphia, Churchill Livingstone, Elsevier; 2010; Volume 2, pg. 2947.
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Vidal V, Muller C, Jacquier A, Giorgi R, Le Corroller T, Gaubert J, etal. Prospective evaluation of PICC line related complications. J Radiol. 2008 Apr; 89 (4) :495-8.
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Guideline for Peripherally Inserted Central Venous Catheters (PICC). Queensland Government. Centre for Healthcare Related Infection Surveillance and Prevention & Tuberculosis Control Version 2 – March 2013; 1-13 Available at: https://www.health.qld.gov.au/qhpolicy/docs/gdl/qh-gdl-321-6-1.pdf
Citation
Desai
DV, Karve N, Gupta AS.Post
PICC Line Thrombosis In a Severely Anemic Post Abortal Patient. JPGO
2015. Volume 2 Number 10. Available from: http://www.jpgo.org/2015/09/post-picc-line-thrombosis-in-severely.html