1. INTRODUCTION
Peripherally inserted central catheter (PICC) has been considered the
favorable venous access protocol for children for decades. It is a light
or non-sedation procedure where a catheter is inserted at a peripheral
site and extended to the superior vena cava with and without the support
of high-resolution ultrasound or fluoroscopic venography with contrast
injected in a peripheral vein of the selected vein for
PICC.1 The procedure can be implemented at the bedside
or in a specialized intravenous suite by trained persons, including
anesthesiologists, interventional radiologists, pediatricians or
specialized IV nurses. 1-3 Due to advancing into the
vena cava, PICC dwelling time can be 390–575 days for infusion and
blood sampling. 1 The long dwelling time contributes
to a decrease in venous access times; thus, reducing pain and anxiety
for children. PICC-associated complications, such as thrombosis,
stenosis and infection have also been reported at low levels compared to
other venous access. 1, 4 Hence, PICC is the
preferable choice for intermediate to long term venous access for
medication, fluid therapy, blood sampling and parenteral nutrition.
Catheter tip location is one of the main focuses in the PICC procedure.
Literature exploring PICC placement has intensively focused on
descriptions of children with normal hearts and normal venous systems.1, 2, 5 Acceptable catheter tip locations for this
group are in the superior vena cava (SVC) or inferior vena cava (IVC)
depending on where the catheter is peripherally inserted, such as in
upper or lower extremities. 1, 2, 5 Acceptable
catheter tip locations contribute to longer patency and lower
complications such as thrombosis, phlebitis and occlusion compared to
those in the non-central or left outside SVC or IVC. 1,
2, 5 Little research has discussed the location of the catheter tip for
children with abnormal heart or venous systems who might have high
demands for venous access for medications or fluid therapy. This
inadequate description could lead venous access teams to mistake the
identification of the catheter tip location, a decrease in the success
rate of the PICC procedure, and an increase in unexpected complications.
This gap justifies the need to provide guidelines for PICC placement for
children with congenital anomalies.
Persistent left superior vena cava (PLSVC) is a congenital anomality
that should be acknowledged when performing a PICC procedure. PLSVC is a
common anomaly of the thoracic venous system that is rare in the general
population, with a prevalence of 0.3%. 6 In children
with congenital heart diseases, the prevalence rate is much higher, at
4.5%. 7 PLSVC results in an unusual position of the
catheter tip in the PICC procedure from a desired position in the right
to the left. 3
Children with single ventricular physiology and PLSVC may receive
palliative surgeries, namely, a bilateral bidirectional Glenn shunt and
Fontan circulation to help them survive. 8 These
surgical shunts also create altered central venous anatomy3, 4, which could cause an unusual catheter tip
location. For patient safety and procedure success, the alternative of
the central venous anatomy should be reviewed and acknowledged prior to
the placement of PICC.
We report two PICC procedures for a toddler having bilateral
bidirectional Glenn shunt and Fontan circulation. Inadequate
understanding about altered central venous anatomy in this patient prior
to the PICC placement among PICC nurses resulted in some unexpected
events. Experience sharing in performing a PICC for this patient aimed
to identify differences in performing PICC for a child with this
condition compared to children who do not and to raise awareness about
the importance of reviewing venous anatomy of patients among PICC nurses
prior to the procedure for the patient safety and procedure success.