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.