I'm in my third semester of nursing school.Tonight at clinical my patient had cellulitis caused by MRSA from a neglected PICC line. Go ahead and laugh at/berate me for my ignorance, but i was confused by her arm that seemed totally fine, but she had 3+ pitting edema that was hot to the touch. BP 90/50, HR in the 80's while on oxycodone, RR 14, temp 97F. Can someone tell me why the cellulitis is in her lower extremities instead of the arm the PICC line had been in?
Sep 19, '12
What evidence was there that it came from the PICC?
Sep 20, '12
It was in her chart. It had been placed to admin antibiotics before surgery because of a previous MRSA infection. Home health nurse failed to show to assess/change it, finally arrived three days late and found her legs swollen and hot. The pt said her face had been "broken out real bad all over", also, though it looked okay today.
Sep 20, '12
Based upon what information you have provided I suspect she is just having an exacerbation of her symptoms from her previous MRSA infection. It sounds like she went home on IV antibiotics to treat an exisitng infection and I bet she was not administering them properly or there was some kind of delay in treatment or the prescribed antibiotic(s) are not sufficient enough for the patient to overcome the infection at this point.
When you have a catheter related infection it is usually a bloodstream infection that you will see and on occasion you may see purulent drainage at the site but gnerally you will see systemic s/sx. There are other types of infections such as a pocket infection or tunnel infection from ports and tunneled types of central lines. In order to state it absolutely caused by a central line such as a PICC there is a very specific set of criteria to follow. Blood cultures should be drawn from a peripheral site and also from the CVC or PICC. It has to be the same organism isolated from both sources and you will usually see a 10-fold increase in the bacteria count form the CVC if that is the source. So if a sample of blood was never taken from the PICC and it was left in place... then they are NOT suspecting that as the source. Once in awhile you will see a line as a confirmed source of infection that they try to treat such a port but it rarely saves the line. Often times MDs do not even bother with this and just have the PICC d/ced an another placed. keep in mind the rate of infection is very very low (1-2 %) for PICCs and with good care many have reported no infections in their facilities.
how old is the PICC?..sounds like it is pretty new...usually if an infection is insertion related or in other words caused by a poor insertion technique..you see infections EARLY in the life of the catheter (within 7 days or so). Once a CVC is getting older it can be blamed more on the care of the line such as noone scrubbing the caps or changing them or a dressing that stays on too long. I am always way more worried about the caps than I am about a late dressing. They have found biofilm in cap housing after just 5 days..so that is way more important then a dressing late a day or two .Dressing can stay on 7 days as long as there is no gauze under the transparent semi-permeable memebrane dressing.
Once bacteria gets in the blood stream it can ,of course cause infection anywhere ,though some locations such as the heart valves get all the pain. Can you give us anymore information. ...did they leave the PICC in..were cultures drawn..is the pt a Diabetic..what are her co-morbitities if any..where was her previous MRSA infection location b/c that could have been the source that carried it to a different location in her body...need more info
Sep 20, '12
Systemic infection would be my thought. That can happen anywhere if for instance, there is a less than sterile technique used introducing a PICC--which travels way beyond the arm into the bloodstream. Have even see it happen when there is not sufficient dressing to cover and protect the insertion site and the patient showers (or doesn't) and the site can introduce lots of germs to the body.
Was the PICC pulled? The tip of the PICC can be cultured to see if this was the route of the infection.
The rash on face? Was the patient put on Vanco? Too fast of a infusion rate can cause redman's which looks somewhat like a rash on the face.
Don't ever think yourself ignorant. You asked some very valid questions. Don't ever stop asking questions, that is how we learn.
iluvivt has explained it beautifully.
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