3. DISCUSSION
Inadequate instructions about performing PICC for children with potential altered or abnormal central venous anatomy contributed to risks and an inaccurate approach in this patient. The PICC nurses did not have foreknowledge about the bilateral bidirectional Glenn shunt and the persistence of the left superior vena cava in this patient. This knowledge gap led to some incorrect actions when performing two PICC procedures and potential risks for this patient. Multiple attempts at cannulation in the first PICC procedure could contribute to intravascular injury and hematoma formation. For patients with a Glenn shunt, this problem could result in stenosis and thrombosis for the SVC and limit adequate passive pulmonary blood flow 9, 10, which may cause the obstruction of pulmonary blood flow, a life-threating event for patients with this post-operative condition.4, 9, 10 In addition, lack of awareness of the PLSVC prior to the second PICC procedure led the PICC nurses to give an inaccurate decision of the catheter tip length. The use of external pressure to thread the catheter with resistance to the target length of 24cm in the SVC in the right side could contribute to injury in the left superior cavopulmonary anastomosis and facilitate hematoma formation and then thrombosis. The lack of knowledge in this topic created serious risks for this vulnerable patient. More importantly, this practice could cause multiple negative impacts for other patients with this condition in the nation-wide Heart Center in Vietnam, where about 1,000 open heart surgeries were successfully performed on a yearly basis from 2016 to 2020, in which the Glenn shunt volume was involved in about 25 to 30 cases annually.
Knowledge about PLSVC and altered central venous anatomy in children with CHD has been insufficiently discussed. While most studies and guidelines for PICC placement primarily provide instructions for children with normal hearts and central venous systems1, 2, 5, the acknowledgement of some altered central venous anatomy has been reviewed in only a few studies by doctors, anesthesiologists and radiologists. 3, 4 In Vietnam, there are no official guidelines for PICC. We note that only a few national children’s hospitals can implement this procedure. Most guidelines are grey literature and largely focus on neonates with normal central venous system. Nurses perform PICC procedures with unofficial training and inadequate understanding about central venous anatomy. Therefore, it is vital to explicitly outline altered central venous anatomy in the PICC procedure for nurses to avoid preventable PICC procedure-related complications for patients. Open communication and discussion about PICC cases between doctors, surgeons and nurses about the central venous system prior to the procedure is also routinely required to avoid unexpected complications and maximize the benefits of PICC.