Description of Event or Problem · 1
PICC LINE PLACED WITH SHERLOCK 3CG TECHNOLOGY. SHERLOCK CONFIRMED PLACEMENT OF PICC IN SVC (SUPERIOR VENA CAVA). PATIENT DEVELOPED ARRHYTHMIAS AFTER PICC LINE PLACED. MD ORDERED MULTIPLE TESTS TO FIND SOURCE OF ARRHYTHMIA OVER 2-3 DAYS. CT RESULT SHOWED CATHETER IN RIGHT ATRIUM. PICC LINE WAS PULLED BACK 3CM AND PLACEMENT VERIFIED BY XRAY. PATIENT WAS NOT ON TELEMETRY BEFORE PICC WAS PLACED. PATIENT WAS NOTED TO BE IN NORMAL SINUS RHYTHM PER ECG BARD DEVICE. PATIENT WAS NOTED TO BE IN NORMAL SINUS RHYTHM WHILE UNDER THE CARE OF THE VASCULAR ACCESS RN. ADDITIONAL TESTS REQUIRED DUE TO ARRHYTHMIA AFTER SHERLOCK CONFIRMED PICC PLACEMENT: GATED CTA, CXR, ECHO THE PATIENT WAS STARTED CARDIZEM. NO HEPARIN (ANTICOAGULANT). THE PICC CATHETER WAS SECURED WITH A STAT-LOCK AND DRESSING (PER PROTOCOL). MIGRATION DID NOT OCCUR PER THE KNOWLEDGE OF THE VASCULAR ACCESS RN. BOTH THE SHERLOCK AND ECG CONFIRMATION TECHNIQUES WERE UTILIZED TO CONFIRM PICC PLACEMENT. PICC REMAINED IN PLACE. NO OTHER KNOWN PROBLEM SUCH AS THIS HAS OCCURRED SINCE THE INITIAL IMPLEMENTATION OF THE 3CG/ECG CONFIRMATION SYSTEM. "I HAD NO DIFFICULTY WITH PLACEMENT AT ALL. THE PATIENT DID HAVE A SPINAL CORD STIMULATOR IN PLACE WITH ELECTRODES IN HIS UPPER THORACIC SPINE (THE BATTERY OF THE DEVICE WAS DEAD, SO THE DEVICE WAS OFF). THE CATHETER WAS ADVANCED UNTIL THE P-WAVE SPIKED AND TURNED GREEN. NO NEGATIVE DEFLECTION WAS EVER NOTED. NORMAL SINUS RHYTHM CONTINUED THROUGHOUT PLACEMENT; NO ARRHYTHMIAS OR ECTOPY NOTED. NO COMPLAINTS OR SYMPTOMS NOTED BY THE PATIENT DURING OR AFTER PLACEMENT AS ASSESSED BY MYSELF", VASCULAR ACCESS RN.