Case - PICC line in an unusual position

Dr Nina Nouraeyan - NeoPremLab - Neonatologist at the Jewish General Hospital; McGill University

Case - October 2023

This case involves a baby born at 24+2 weeks gestation with a birth weight of 550g. The baby was assessed on the 7th day of life. A PICC (Peripherally Inserted Central Catheter) line had been inserted previously. Radiographs at that time revealed that the PICC line was positioned to the left of the spine. On radiographs, it was challenging to determine whether it was truly within a vein or in the aorta. Additionally, there was an umbilical arterial line in place, which appeared to run alongside the PICC line. A decision was made to perform a point-of-care ultrasound to assess whether two lines were present in the descending aorta prior to removal of the PICC line (considering the challenges in installing these lines in such vulnerable immature infants). During the ultrasound examination, two clearly defined lines were visualized within the descending aorta. We attempted to infuse fluid to observe whether there were any echogenicity changes when infusing into the umbilical arterial line as opposed to the PICC line, but we were unable to discern any such differences.

Arterial blood gas evaluations were performed using samples from both lines:

Gas from the UAL: pH 7.28, pO2 56 mm Hg, pCO2 46 mm Hg, HCO3 26 mEq/L, BE -1.2

Gas from the PICC: pH 7.26, pO2 56 mm Hg, pCO2 48 mm Hg, HCO3 25 mEq/L, BE -2.5

These results provided additional confirmation that the line was improperly placed within an arterial compartment.

We subsequently removed the umbilical arterial line (UAL) and repeated the point-of-care ultrasound (POCUS), confirming the presence of the PICC line within the descending aorta. This case serves as a valuable illustration of how POCUS can promptly identify misplaced lines. In future cases where line placement is uncertain, POCUS could be performed immediately after line insertion to prevent inadvertent arterial infusion. This patient did not have any complications related to peripheral arterial infusion.

Concerning trajectory of the PICC line placed in the lower limb, running parallel to the spine and to the umbilical arterial line, bringing a suspicion that it may be misplaced into an artery and not in a vein.