Optimizing the tip position of a peripherally inserted central venous catheter under a multidisciplinary team approach in a patient with mirror-image dextrocardia: a case report

Abstract

Peripherally inserted central venous catheters (PICCs) are widely used in cardiology because they are convenient, effective, and safe. However, PICC implantation in patients with mirror-image dextrocardia who have thoracic tumors has not yet been reported. In this case report, we describe a 46-year-old patient with lung cancer who had a thoracic inclination and left pulmonary artery compression of the superior vena cava. PICC implantation under B-ultrasound guidance was planned. Because of the anatomical differences caused by mirror-image dextrocardia, we investigated the optimal position and measurement method for the tip of the PICC according to the compression site of the vascular lumen through a multidisciplinary team approach. Electrocardiography-assisted tip positioning combined with postoperative chest X-ray positioning was performed for accurate positioning.

Introduction

The positioning of the heart on the right side of the chest is referred to as dextrocardia. It is a rare congenital heart condition with an incidence of approximately 2 per 100,000 individuals. ¹ Mirror-image dextrocardia refers to the positioning of the heart on the right side of the chest with the atrium, ventricle, and great vessels appearing as a mirror image of the normal heart. This type of dextrocardia is usually accompanied by visceral transposition, but it has little impact on health and quality of life. However, ectopic tissues may cause several problems in patients who have cardiopulmonary disease or have undergone medical device implantation. We herein describe a patient with mirror-image dextrocardia who, after comprehensive evaluation, underwent successful implantation of a peripherally inserted central venous catheter (PICC) in the left upper limb. To ensure the patient’s satisfaction with nursing care and increase his or her quality of life in cases such as this, it is important to reduce the frequency of adjustment of catheterization and the deviation between the actual length and the measured length of the PICC tube through precise positioning. This is a rare case. The method proposed in the present report can provide a basis for further clinical nursing work.

Case presentation

This case study was approved by the Medical Ethics Committee of Army Medical University (approval number 2021 (204)). The patient voluntarily participated and provided written informed consent. The study is reported in line with the CARE guidelines. ²

A 46-year-old patient underwent enhanced chest computed tomography (CT), which showed visceral inversion of the chest and upper abdomen with a possible diagnosis of mirror-image dextrocardia. In 2019, the patient had been diagnosed with advanced adenocarcinoma of the right lung (T3N1M1), and the disease had progressed after multiple lines of treatment including chemotherapy, radiotherapy, targeted therapy, and anti-angiogenic therapy. The patient was hospitalized on 11 May 2021 in generally poor condition with symmetrical edema of the limbs, coagulation disorder, and severe anemia and hypoproteinemia that required parenteral nutritional support. The peripheral veins can only tolerate short-term hypertonic fluid infusion, ³ and the patient’s peripheral blood vessels were thin and stiff after repeated treatment. Therefore, central venous catheterization was performed.

The patient was diagnosed with mirror-image dextrocardia, and the structure of the heart was abnormal. A comprehensive evaluation was conducted after consultation with the venipuncture group and the radiology department. With the patient under local anesthesia, specialized nurses performed PICC catheterization under B-ultrasound guidance using the modified Seldinger technique combined with electrocardiography (ECG)-assisted intracavity electrical tip positioning to reduce complications. ⁴ The operative process was as follows.

The preset insertion length was measured in a conventional manner: the patient’s arm was abducted at 90 degrees in the supine position, and measurement was performed from the pre-puncture point along the vein to the right sternoclavicular joint and then folded down to the third anterior rib. The position of the heart was a mirror image of the normal anatomy. A multidisciplinary team (MDT) comprising specialists from the cancer center, department of respiratory, and department of radiology of our hospital confirmed that the preset insertion length was 36 cm through body surface measurement in combination with assessment of the patient’s body position, thoracic inclination, superior vena cava (SVC) compression, and arm adduction.

The patient underwent oxygen inhalation via nasal catheter in the orthopneic position because of the inability to lie flat. This was followed by three routine preoperative preparations. A small table was set on the left side to abduct the left upper limb by 90 degrees. The arm circumference at 15 cm below the acromion was measured as 26 cm. The brachial vein was chosen as the target vessel based on B-ultrasound (Bard Site-Rite5 (Vision 5); BD, Franklin Lakes, NJ, USA) and had a diameter of 0.3 cm and a depth of 1.0 cm. An intracavity ECG monitor (C100; Shenzhen Comen Medical Instruments Co., Ltd., Shenzhen, China) was also used during the procedure. The assistant placed one electrode labeled “RA” in the first intercostal space on the midclavicular line at the left edge of the patient’s sternum and one electrode labeled “LA” in the first intercostal space on the midclavicular line at the right edge of the patient’s sternum. The final electrode labeled “LL” was placed at the lower edge of the right costal arch to obtain a basal electrocardiogram (Figure 1). The electrocardiogram showed consistent sinus rhythm, and a lead II electrocardiogram was recorded. A silica gel 4-French PICC with a three-way valve was used (Bard Co., Ltd.). The operator established a maximum sterile barrier and performed a successful puncture using one needle. This was followed by delivery of the tube to the preset length at a uniform speed. An assistant connected one end of the sterile lead wire to the RA electrode with an alligator clip at the other end to the PICC support guide wire for continuous tube delivery. An electrocardiogram was recorded when the amplitude of the P wave reached 41 cm and negative and positive two-way waves occurred.

Figure 1.

Electrocardiography-assisted tip positioning combined with postoperative chest X-ray positioning was performed for accurate positioning.

When the catheter was withdrawn to 39 cm, the P wave showed the maximum amplitude. After retreating 1 cm (to the optimum length of 38 cm), the P-wave amplitude decreased by 50%. This was defined as the cavoatrial junction (CAJ) point. Based on the opinion of the MDT, the catheter tip was moved 2 cm away from the compressed part of the SVC, and the final insertion length was 36 cm. The remainder of the entire operation was efficiently completed. A plain chest film was used to confirm the position of the catheter. After the successful puncture, the patient received nutritional support and the symptoms were relieved. The patient was then transferred to a local hospital for further treatment.

Discussion

A PICC is mainly used for venous puncture in the peripheral arm. The tip of the catheter is placed close to the SVC, which has fast blood flow. Drugs can be diluted quickly, helping to prevent the stimulation of blood vessels by drugs. ⁵ Many studies have confirmed that the PICC tip stimulates the heart sensors and blood vessel walls, resulting in palpitation, chest tightness, and even arrhythmia and pericardial tamponade when placed at greater depths. However, when the catheter is placed at a shallow depth, the vascular cavity becomes relatively narrow and the risk of friction between the tip and the vascular wall increases. This results in vasospasm, intimal injury, vascular wall perforation, and even aseptic mechanical inflammation and thrombosis of the venous wall. ⁶ Additionally, patients with cancer have been shown to have a high incidence of venous thrombosis ⁵ with a significantly increased risk of serious complications; thus, precise positioning of the catheter tip is critically important. Through MDT discussions, the patient in the present case underwent accurate positioning of the PICC tip based on the factors discussed below.

Selection of catheter placement position

In 2014, the first health industry-standard “Operation Specification for Intravenous Therapy Nursing Technology” issued by the Health Commission of China suggested that thin, short catheters should be selected to meet treatment needs. The right path is shorter than access from the left and right upper arm veins to the SVC; therefore, PICC implantation is usually performed along the right path. In our patient with mirror-image dextrocardia, the left path was shorter and was therefore the preferred route because of the interchanged positions of the intrathoracic tissues. During the imaging consultation, we found that the diameter of the right brachiocephalic trunk vein was narrowed because of thoracic collapse and the inclined tissue structure (Figure 2). The patient was in a sitting position, which was not conducive to catheter placement. The lack of mobility of the lower limbs also increased the risk of thrombosis. After considering these factors, left arm implantation was recommended.

Figure 2.

Computed tomography image showing that the diameter of the right brachiocephalic trunk vein was narrowed due to thoracic collapse and the inclined tissue structure.

Changes in body surface positioning caused by chest inclination

The Infusion Nurses Society recommends the performance of routine chest X-ray examinations after PICC catheterization to determine the location of the catheter tip. The tip should be located in the lower one-third of the SVC at the connection between the SVC and the right atrium (i.e., the CAJ). ⁷ In the present case, the body surface projection of the CAJ was on the upper edge of the right third costal cartilage.

Our patient had advanced-stage cancer in the right lung with lung tissue atrophy and displacement of the mediastinum. This resulted in collapse of the right thorax and upward inclination of the left thorax. Consequently, the corresponding relationship of the body surface location points could not be explored using conventional methods. Based on CT imaging, the difference between the left and right ribs of the patient reached 2.0 to 2.5 cm (Figure 3). Considering these data combined with the degree of thoracic inclination, and after consultation with the radiology department, we determined that the optimal body surface positioning point of the patient should be moved down by one rib. The body surface measurement endpoint of the CAJ was adjusted from the third anterior rib to the fourth anterior rib, and the measured length was 38 cm, which was consistent with the ECG results.

Figure 3.

Based on the computed tomography image, the difference between the left and right ribs of the patient reached 2.0 to 2.5 cm.

Adjustment of tip retention position due to compression of SVC by left pulmonary artery

Although the patient had previously received various treatments for nearly 3 years, the tumor progressed. CT images showed that the SVC and aortic arch were located on the left side. The change in the direction of blood vessels resulted in compression of the SVC by the left pulmonary artery and stenosis proximal to the atrium. However, no other areas of the heart were compressed, and the CT images did not support a diagnosis of SVC syndrome (Figure 4). The SVC has the largest diameter and fastest blood flow, making it most suitable for insertion of the catheter tip. The lower part of the SVC connecting the atrium was compressed and narrowed in our patient, causing blood reflux. Thus, the SVC was not suitable for placement of the PICC tip.

Figure 4.

Computed tomography image showing no evidence of a diagnosis of superior vena cava syndrome.

The 2016 Infusion Nurses Society guidelines indicate that adjusting the PICC tip to the correct position leads to an increased risk of deep vein thrombosis.^8–10 In the present case, the SVC was 6 to 8 cm long, and the middle and lower thirds were around 2 to 3 cm long. The vessel diameter at the stenosis of the SVC proximal to the atrium as measured by CT was 0.146 cm. The diameter of the 4-French catheter was 0.133 cm, and the catheter-to-vessel ratio was 91%. These findings suggest that this was not the optimum position for catheter placement. Additionally, the diameter of the SVC was 0.306 cm, and the catheter-to-vessel ratio was 43%.

By comparing the internal diameter of the SVC obtained from the CT images, the radiologists suggested that the catheter tip should be moved by 2 cm and positioned to the left at the broadest part of the SVC to prevent intimal injury and thrombosis. This method avoided the stenosis while the tip of the catheter was still located in the lower and middle parts of the upper lumen. Consequently, the preset length of the catheter was reduced by 2 cm from the basic measurement value (final insertion length of 36 cm).

Effect of arm adduction and abduction on tip position during catheter indwelling

Connolly et al. ¹¹ reported that the effect of limb abduction and adduction on the position of the catheter tip should be considered when determining the length of PICC catheterization. De Carvalho and Eagar ¹² showed that the position of the catheter tip in most patients moved by a mean of 1.4 ± 6.5 cm to the right atrium when the limb was abducted from 90 degrees to adduction. In the present case, the patient’s left limb was abducted followed by adduction after catheterization, and the routine body surface position was adjusted. After a discussion, the MDT members suggested that 2 cm should be added to the original standard measurement length. The measured length changes caused by arm adduction and abduction were included with the stenosis due to the compressed SVC. Thus, the preset length of the catheter was reduced by 2 cm from the basic measurement value, with a final insertion length of 36 cm.

Limitation of this case report

This case report was intrinsically limited by the fact that the data were obtained from an individual patient. This prevents a statistical analysis based on a patient population, and a causal relationship between the clinical outcome and clinicopathological characteristics in question therefore cannot be determined.

Conclusions

In this study, we aimed to optimize a method to measure the insertion length of a PICC in a patient with cancer who had mirror-image dextrocardia. Intracavitary ECG and CT imaging measurements of the catheter length are significantly more accurate than the measurements obtained on the body surface. The relative position, compression of vascular lumens by the tumor, and body position may impact the implantation length; thus, it is vital to correctly identify the optimum position of the catheter tip, which is challenging during routine operations. Multidisciplinary research should be conducted by radiology departments, PICC specialist nurses, and other relevant departments to comprehensively evaluate the overall situation for individual patients. Accurate measurements allow ideal placement of the PICC tip to reduce the adjustment of catheterization, the deviation between the actual length and the measured length, and the incidence of complications. The retention time can be prolonged to improve patients’ quality of life.

This study demonstrated the value and efficacy of an MDT approach in PICC nursing. ¹³ However, given that the incidence of mirror-image dextrocardia is rare and cases of complex PICC catheterization are limited, it may be particularly important to standardize and evaluate MDT cooperation in exceptional patients.