A 59 year old white male was transferred from an outside hospital with back pain, fever and neurological deficits and found to have an epidural abscess with MRSA positive blood cultures. Emergent debridement and drainage of abscess without complications was performed and a PICC line was inserted for long term antibiotics. A chest x-ray showed the tip at the cavo-atrial junction. On the night of insertion he had two episodes of asymptomatic runs of supraventricular tachycardia (SVT) lasting for several minutes. He had no history of arrhythmias and had been uneventful on telemetry while in the hospital. A chest x-ray was obtained to recheck the PICC line position which was unchanged. Nonetheless the PICC line was retracted by 2-3cm and repeat imaging showed it to be in the mid superior vena cava. After retracting the line there were no further episodes of SVT. We were not aware of our patient’s arm position during his runs of SVT.
Peripherally Inserted Central Catheters (PICC) are commonly used for prolonged intravenous access in acute care, home care and skilled nursing facilities. The incidence of new atrial arrhythmias from a central venous access device is up to 41% and 25% for ventricular arrhythmias however clinically significant arrhythmias from PICC lines are not well described or reported in literature.
PICC lines have several risks and complications including infection, phlebitis, air embolism, thrombus formation, malposition of catheters, nerve injury, difficult removal and occasional breakage of catheters. Cardiac arrhythmias including SVT and ventricular tachycardia are rare complications of PICC lines based on our literature search. PICC lines are inserted by the well trained PICC teams or interventional radiologists and the position is routinely confirmed with a chest X-ray. The ideal position being two centimeters below the sternoclavicular joint but in cadaver studies PICC lines inserted via the basilic veins can move up to 2.8cm with changes in arm position. A few case reports showed inward movement of the tip of the PICC with adduction of the arm causing arrhythmias and resolution of arrhythmia with retraction of the line. Arrhythmogenic complications also include life threatening ventricular arrhythmias. These arrhythmias may be refractory to treatment due to the mechanical irritation caused by the catheter. Patients with newly developed or worsening arrhythmia must have the position of the PICC line evaluated and it should be considered as a possible etiology.
Patients with PICC lines who develop new or worsening arrhythmias require careful evaluation of the position of the catheter and relation with arm movements. Retraction of the PICC by a few centimeters can resolve the arrhythmia and decrease unnecessary costly cardiology evaluation and treatment.