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.