Post PICC Line Thrombosis In a Severely Anemic Post Abortal Patient

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 1/3^rd 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 4^th  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

1. 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
2. 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.
3. 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.
4. 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.
5. 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