Summary of MedSun Reports Describing Adverse Events With Peripherally Inserted Central Catheters
MedSun: Newsletter #51, August 2010

The Peripherally Inserted Central Venous Catheter (PICC) is a flexible catheter with proximally located luer lock adapter(s) with a pressure activated safety valve, extension tubes, and suture wings for catheter securement that is inserted into a peripheral vein and advanced to the superior vena cava. The PICC is available in single, double, and triple lumen configurations [1]. “The catheter is radiopague and may be provided as a stand alone device or the catheter may be provided in a kit with other legally marketed products”[2].

“The PICC device is indicated for short or long-term peripheral access to the central venous system for intravenous therapy, including but not limited to the administration of fluids, medications, and nutrients, the sampling of blood, and for power injection of contrast media” [3]. “The PICC is generally selected for IV therapy that is prescribed for less than 6 to 8 weeks. Although, a PICC may indwell for a shorter period, the average indwelling time for a PICC is 2-6 months. The basilic, cephalic and median cubital veins of the arm are the preferred locations for PICC insertion in adults; scalp veins such as the posterior auricular and temporal veins may be used for neonatal patients. For pediatric patients, the saphenous, popliteal, and femoral veins of the leg may be used, with the tip location in the inferior vena cava” [4].

Over the past year, MedSun has received 46 adverse event reports associated with the PICC device manufactured by the following manufacturers:
• Becton Dickinson
• Bard Access Systems, Inc.
• Cook Medical
• Teleflex Medical
• Medcomp
• Covidien
• Vygon
• Navilyst Medical

These reports were submitted by 34 hospitals between 07/2009 and 07/2010. The most frequently reported device problems were:
• 21 reports associated with catheter breaks
• 9 reports associated with the structural material (hole in material, frayed, knotted, torn,
• 9 reports associated with leakage
• 3 reports with no associated device problem
• 2 reports associated with catheter fractures.
• 1 out-of-box failure (kink in the catheter).
• 1 report of the catheter bursting.

None of these reports resulted in a patient death, although patient injuries (listed below), were reported in 11 of these 46 reports.
• 3 reports of device fragments in the patient
• 2 reports of dyspnea
• 2 reports of erythema, swelling, edema, and, ecchymosis
• 1 report of thrombosis
• 1 report of underdose
• 1 report of embolus
• 1 report of vasopasm

Of the reports that listed patient age, 22 reports had a patient age listed as less than 21 years and 16 reports had a patient age listed as greater than 21 years. Of the reports that listed patient gender, a total of 15 reports involved female patients and a total of 21 reports involved male patients.

These MedSun reports contributed to FDA awareness of these types of device problems. FDA continues to investigate these problems. If you have experienced problems with the use of PICCs, please report them to the FDA.


Summary of MedSun Reports Describing Adverse Reports between July 2009 and July 2010 with The Peripherally Inserted Central Catheter
Device Device Identifiers Event Description
Becton Dickinson Catalog 384466, Lot #’s 7114730, 9113195, 9063169, 9063769 A 2.6 French dual lumen BD catheter was placed. Eight days later the catheter was noted to have leakage from the blue port at the bifurcation, but then stopped. Two days later at noontime, the blue port again was noted to be leaking at the bifurcation. The infant was also noted to be febrile and had an elevated white count. After extensive team discussion, the decision was made to clamp off the blue port and use as a single lumen. Later on that day at 1600, the red port was noted to be leaking. A decision was made to remove the line. The patient currently has a single lumen broviac used for parental nutrition/intralipids, dopamine, opioid infusion, and has an 8 French left internal jugular hemodialysis catheter. Additional access was required for triple antimicrobial coverage and sedation. After eight attempts, a peripheral IV was placed in the right foot. There have been recent incidences of leaking of BD dual lumen catheters elsewhere in the hospital over the past few months for which a practice alert had been sent. At that time a NICU CNA checked all lot numbers in the unit and confirmed lot numbers were not included in those reported as defective. A decision was made not to remove from stock given that there was no available replacement of appropriate size.
Bard Access Systems, Inc. 5 FR PowerPicc with Sherlock tip location system (TLS) stylet Catalog 9275118, Lot #REUA1183 A female patient was admitted with respiratory and cardiac issues. A PICC (peripherally inserted central line) was inserted and a routine post insertion chest film revealed what appeared to be a 6 cm wire fragment in her axilla vein. The wire fragment is presumed to be from the tip of the stylet wire used to insert the catheter. An interventional radiologist physician removed the wire fragment without difficulty.
Becton Dickinson 2.6 French 20G double Lot# 9113195 A surgically placed 2.6 double lumen BD L-catheter PICC was leaking. The PICC was noted to have small amount of blood on dressing after lab draw 1-2 weeks ago. At the time the RN changed the dressing, flushed the line, and saw no further leaking. Use of the line was resumed. Yesterday after a lab draw, blood again was noted under the dressing near where catheter enters the white bifurcation. The dressing was again changed and line flushed with no visible leaking. Use of line was resumed. The lot number of line is 9113195, which is the same lot # as last leaking line. Labs were drawn and lines flushed only with 10 ml syringes per RN. No sutures are on the line itself only through the wings securing to skin. The plan for this patient was discussed with NICU and surgical attending with the risks and benefits of changing the line discussed. Attempt will be made by NICU team to place new PICC. If unsuccessful, alternative options will be discussed at that time. A meeting is planned for tomorrow with products, IV team, nursing, and surgery to discuss PICC product options moving forward.
Cook Medical, PICC Peripherally inserted CVC set with Nitinol Wire Guide Catalog# G36221; PICS-501-MPIS-NT-ABRM At the beginning of the shift it was reported that the end of patient's inserted PICC had came off along with the green cap. The catheter was still clamped. The team was notified. The pediatric surgeon was consulted and discussed new line placement with patient's mom. The catheter was dressed with chloraprep pads and alcohol, and then secured with foam tape to patient's chest. A new peripheral IV was started to make sure the patient received his antibiotics.
Cook Medical, PICC Peripherally Inserted CVC Set with Nitinol Wire Guide Catalog#G36221; PICS-501-MPIS-NT-ABRM Mom had put the call light on for the nurse to flush the placed PICC because the clamp had come undone. I flushed the line with saline with no problems, and then heplocked it. Patient & Family-Centered Care (PFCC), and charge nurse notified
Bard Access Systems, Inc. Brand name: Groshong NXT PICC Lot # REUC0254 A patient presented to the outpatient department for a PICC dressing change and brought to the nurse's attention that a wire appeared to be inside the PICC tubing. The nurse was also able to visualize this wire. This PICC line was removed and replaced with another PICC, Groshong. An x-ray was taken of the patient's chest following removal of the guide wire which confirmed proper placement with no issues identified. The patient was discharged. The PICC in question was x-rayed and it was determined that there were two pieces of the guide wire inside the Groshong. The hospital staff then tested a second PICC (#2) from a new package (lot# REUB1198) by running it gently through their fingers upon which the guide wire was noted fractured just above the magnetic rings. A similar issue was discovered involving a different type of PICC kit, which also included the Sherlock guide wire from a different facility in the organization (lot# RETK0645) Power PICC with Solo catheter. This kit was also returned to the manufacturer for evaluation. All BARD PICC kits in the organization, which included the Sherlock guide wire were pulled from stock and returned to the manufacturer for replacement stock.
Cook Medical, Brand name PICC Peripherally Inserted CVC Set with Nitinol Wire Guide Catalog# G36221; PICS-501-MPIS-NT-ABRM Centrally placed PICC needed to be flushed because the clamp had come undone.
Vygon, Brand name: LifeCath 1.9Fr PICC unknown Silicone PICC was found broken with blood and fluid leaking out of the device into the bed. The volume of fluid loss was estimated at 1-2 milliters. There was an abrupt interruption of IV nutrition. There was no repair kit available for this device (it was from another hospital). The device was ultimately repaired with another Vygon brand catheter. Break of line = risk of infection. The time to repair was about 30 minutes, which caused an interruption of IV nutrition. The effect on the blood sugar was unknown.
Bard Access Systems Catalog# 0600040, Lot# RETH0401, When checking the patency of the line prior to placement, it was noted to have a hole in it.
Vygon, Brand name: Vygon Premicath Model 1261.203, Catalog 1261.203 28G (1Fr), Lot#041580 A premature neonate was born by emergency Caesarean and was admitted to the NICU for management of issues related to his prematurity. The next day the neonate underwent the insertion of a peripherally inserted central catheter (PICC) for long term intravenous access using a Vygon Premicath Model 1261.203 1Fr catheter. The PICC was placed without incident and chest x-rays were done to facilitate and confirm placement. The line was subsequently used to deliver intravenous fluids and total peripheral nutrition without complication. On day seven, during a routine IV tubing change, the nurse disconnected a connector and discovered that a guide wire was still in place within the PICC catheter. The neonatologist was notified and the guide wire was easily removed. The wire appeared to be fully intact. The length of the wire was compared to a second wire from an unused kit and they were identical in length. A chest ex-ray was obtained after the wire was removed and the PICC line remained in good position. The neonate suffered no harm nor was there a change in treatment plan based on this event. The package insert that indicates that the stylet needs to be removed is labeled with a size 6 font with a gray color on an onion skin paper. The neonatal intensive care unit had recently switched to this brand of 1 Fr PICC line, which has a guide wire in place within the line to provide extra rigidity for easier advancement. The guide wire is attached through a port that closely resembles an access port for intravenous fluids. There are no identifying markings on this port and the guide wire is not visible. There are no labels or inserts indicating the presence of the guide wire. No previous brands or models of 1 Fr PICC lines used by NICU clinicians had contained guide wires including a similar model - Vygon Premicath 1261.20 -- staff were not accustomed to the presence of the guide wire.
Unknown Unknown A broviac central line became occluded. TPA (tissue plasminogen activator) was used times two in an attempt to clear the line. When this was unsuccessful, the line was changed out in the OR and a piece of the catheter sheared off and lodged in the heart. It is unclear what surgical techniques were used as part of the catheter exchange. A cardiac catheter was performed to retrieve the foreign body from the heart. The patient did not have any complications from the catheter. The device may not have contributed to the event. It could have been surgical techniques that were used to remove or exchange the occluded catheter.
Bard Access Systems, Inc. Brand name: PowerPICC Model/Catalog 9275118 Lot#REUA0719 The guide wire fragment was seen on x-ray. A review of the diagnostic film traces the fragment to the line inserted 20 days prior. There was an attempt to retrieve the fragment in interventional radiology, and the retrieved part of the fragment. Additional smaller fragments remain in the pulmonary vasculature and are unable to be retrieved. The removed fragment is in possession of Risk Management at the hospital.
Bard Access Systems, Inc. Brand name: Bard Dual Lumen 12F Hickman Lot# HUTK0519 The device failed and needed to be replaced with another double lumen catheter because there was leakage from the catheter due to several pin holes on each lumen.
Navilyst Medical, Inc. Brand name: Vaxcel Model 46-457 Lot# 1373688 A patient had a PICC line in their right arm. The nurse removed the cap, drew blood, and then connected IV tubing to the PICC line. Vancomycin was infused through the PICC line. At the end of the infusion, the line was flushed with saline. The nurse was unable to disconnect the line, and the tubing broke off with the male connector still in the PICC line. The PICC line was removed and patient had to have a new PICC line placed.
Bard Access Systems, Brand name: Sherlock Catalog#9755305, 9655405, 9857505,9957505 Lot#RESG0681,RETB0533,RETG0274, RESI0937, RETI1043, RETK0881,RESF 0289 Other device# 3 FR Groshong, 4 FR Groshong, 5 FR 45 cm Groshong, 5 FR 55 cm Groshong For approximately fourteen months, it has been noted that in nine patients a "reaction" has occurred after flushing with normal saline following PICC placement. We began using the Sherlock wire in these catheters approximately five months before the first reported adverse event. There seemed to be a vagal/histamine reaction, with signs of tightness in throat, and puffy eyes. With the latest case, the patient had increased coughing associated with redness in face. The patient denies shortness of breath. At first, we thought that it was because of the power flush after the placement. Now, we think it may be the wire.
Bard Access Systems, Brand name: PowerPICC Solo Catalog# REF 91941080, Lot#REUB0619 The Pt had a PowerPICC Solo line placed in the right upper arm (RUA). IV antibiotics were hung and the PICC was flushed and running fine. The next morning, the pt awoke and the RN found the RUA PICC bulb end disconnected from the catheter. It was in the bed beside the pt. There was no back bleeding observed within the lumen of the catheter. The pt was asymptomatic for air embolus and the catheter line portion was removed intact.
Mfr. Unknown, Brand name: Groshong Central Venous Catheter unknown A Pt was sent to the hospital for the removal of a fractured Groshong catheter that was within the right atrium and right ventricle. This admission occurred when the pt's physician (outside of this facility), realized during an attempt to remove the catheter, that the catheter was only partially removed (part had fractured internally).
Becton Dickinson Infusion Therapy Systems, Inc. Unknown During a 26 gauge PICC line dressing change, the PICC catheter broke from the hub. The break occurred approximately 0.5cm past the disc portion of the catheter. It is unknown why the catheter broke.
Bard Access Systems, Inc. Brand name: PowerPICC Solo Catheter Catalog# REF 9295108 Lot#REUB0167 During a PICC insertion, there was an equipment failure. The healthcare professional was unable to thread the introducer over the guide wire. It had a defect that was not visible, but a rough area could be felt on the wire. A larger introducer was opened and threaded over the wire without incident. There was no patient harm.
Bard Access Systems, Inc. Brand name: Bard PowerPICC Catalog# REF 9295108, lot#REUB0167 During a PICC placement a hub was attached to the PICC. There was no blood return and the PICC was difficult to flush. The PICC was pulled back and still there was no blood return with flush. The patient's basilic vein vasospasmed and resistance was met. The patient started coughing and the PICC was removed. Noted: magnetic tip sticking out from PICC tip. The wire was pulled from the hub end to make flush with the cut PICC portion, but it did not retract. Pulled entire wire from PICC and magnetic tip stayed in place at cut end of PICC. Pulled magnetic tip out and there was approximately 3-4 cm of wire that had been broken from other portion of wire.
Covidien, Brand name: Argyle Catalog# 43303 A neonatal PICC was placed in an infant. The pigtail was noted to be leaking approximately 1 cm from where the pigtail joins the luer connector. The catheter was removed after several unsuccessful attempts to replace it. The infant was taken to the operating room for surgical placement of a central venous catheter. Of note, this is the 13th similar occurrence of leaking in the same area of the 1.9 French catheter over an 18 month period of time. During the process to determine if the leaking was a practice or product related issue, we examined our practices related to PICC insertion, care, and use. We could not find any common threads. As a result, we provided the rep with 3 (of the 13) catheters to be examined microscopically for clues to any product inconsistencies or reasons identified for the leakage. In the meantime, we have removed the product from our storeroom and substituted a product from another manufacturer. We don't know, but given that we examined our own practices for the possibility of user error, it is possible that there is a device quality control issue.
Bard Access Systems, Inc. Brand name: Power PICC Catalog# 9275118, Lot#RETL0614, Other#91906 A PICC line was placed without incident. A linear hyperdensity of an unknown etiology was observed on chest x-ray. A PICC guide wire fragment was removed. We do not know how this event happened. There is concern of a potential manufacturer defect.
Bard Access Systems, Inc. Brand name: Power PICC Solo Catheter Catalog# 9194118, Lot# RETI 1012 During the procedure to insert a single lumen PICC catheter, the healthcare professional had difficulty advancing the catheter into the vein. A decision was made to change the catheter over wire to a dual lumen catheter. The Sherlock guide wire was removed from the catheter with the tip appearing intact. The catheter was trimmed to 10 cm and a hardwire was inserted into the catheter. The old catheter was removed over the wire and 5cm of Sherlock guide wire were found next to the hard wire. The practitioner proceeded to pull both wires out at once and stopped the procedure. There was a fracture of the Sherlock wire that was about 5cm from the end of the wire.
Bard Access Systems, Inc. Brand name: Groshong CV Catheter Catalog#7726954 This replacement catheter was being flushed at the time by the nurse when one of the lumens of the double lumen catheter broke off. It remains in the patient.
Bard Access Systems, Inc. Brand name: PowerPICC Catalog# 3175108, Lot#RETG0980 The RN was inserting a PICC in patient's right arm. The guide wire frayed and was lodged in the patient's arm. The RN was unable to remove at bedside.
BD Medical Systems, Brand name: BD First PICC Lot#8231654 A night nurse completed a heel stick on the infant and noted edema on the infant's chest area. Upon further review edema noted on bilateral chest area to abdomen with ecchymosed area on upper center of chest just left of midline. PICC infusion stopped at this time and PICC line removed. Approximately two hours later, the dayshift RN measured dark red/purple area on chest at 3.5cm by 2cm in an oblong shape across upper left chest with redness noted radiating out from demarcated line of purple area to under chin and to sternum. Edema noted across chest extending to mid-maxillary line bilateral and down beyond sternal border on right side to lower abdominal quadrant. The entire area soft, and appears non-tender when palpated.
Teleflex Medical Catalog#55064, Lot#RF9086053 The practitioner was called in the morning regarding a "defective PICC" by a nurse in the ICU. The patient had a 5Fr two lumen power injectable PICC inserted. The nurse stated that yesterday she noticed the "port" was separated from the catheter. When investigated, it was found that the pink hub was missing from the catheter. The catheter was clamped right below the missing portion. Tegaderm had also been wrapped around the catheter. The nurse was advised that the catheter would have to be replaced and to notify the MD.
Bard Access Systems, Inc. Brand name: Per-Q-Cath Catalog# 4133110, Lot#REFH0040 A male presented to the emergency department with ulcers to the right foot a week prior to the reported event. During a dressing change, he pulled the skin off the right great toe and it "started spurting blood and pus." He was a known diabetic under treatment for insulin dependent diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease, attention deficit hyperactivity disorder, obsessive-compulsive disorder, and back pain. He was admitted to the medical surgical floor with a diagnosis of diabetic right foot infection with an infected ulcer over the first MP Joint and uncontrolled diabetes mellitus. He received IV antibiotics, warm soaks to the right foot, and dressing changes. Two days later, he was taken to OR for excision debridement of the right foot, right big toe and opening of the metacarpophalangeal joint. As long-term antibiotics were planned for osteomyletis, the physician ordered a PICC inserted by nursing. Two days after the OR procedure, the PICC line was inserted by a seasoned RN with certification in PICC insertion and 13 years experience in this procedure. On the third attempt, the line was placed in the left antecubital basilic. The entire catheter of 19.5 inches was inserted with 0 inches on the outside. Three days after insertion, the PICC line was removed per order by the same RN who inserted the line. After warm soaks were applied to the arm, the PICC line was removed with minimal traction. The tip appeared to be angle cut (as was cut on insertion), but the line only measured 18 inches. At that time, the nurse was curious and tested the line's strength. She "pulled minimally on it and it snapped very easily." In her 13 years of experience, she has never seen a line so fragile. The surgeon on call was notified and a portable chest x-ray was ordered. The x-ray confirmed that part of the catheter remained in the vein, "a 6.2 cm linear density was noted on the more medial aspect of the distal arm just proximal to the elbow consistent with residual PICC line." The surgeon on-call expressed confidence to the RN that no migration should occur as the catheter is in a superficial vessel at the elbow region. A plan was made for the surgeon to remove the PICC residual foreign body two days later and at that time to insert a Mediport. The Mediport was inserted as planned without difficulty, but after venotomy and further fluoroscopy from the elbow to the subclavian, the surgeon was unable to locate the foreign body. A plan was made for x-ray the next day for location of the foreign body. A chest x-ray done the next day revealed a 4.3 cm fragment of the PICC line overlying the right chest in the pulmonary artery. Fluoroscopy and x-rays of the right arm on the same day showed no radiopaque foreign body. Plans were made for transfer to a tertiary facility for removal of the broken PICC line in the right pulmonary artery. Throughout the hospital stay, patient has maintained good blood flow to the arm and free of respiratory symptoms.
Becton Dickinson, Brand name: L-Cath Model 1.9 Fr. A PICC line was inserted one day prior to the event and was infusing well. While doing a routine IV check, the catheter was noted to have snapped off at the hub.
Becton Dickinson Infusion Therapy Systems Catalog#384467, Lot#7170231 A PICC line was discovered to be leaking at the junction where the tubing from the blue port meets the white molded wingset. Attempts to insert the same type PICC line were unsuccessful, and a femoral line was inserted instead.
Medcomp, Brand name: Vascu-PICC Model 3 Fr. Lot# MAVY910 A 3 French Vascu-PICC catheter luer hub cracked during a cap change procedure. The patient had been receiving daily cap changes with blood draws. The PICC was initially placed 12 days prior to the event. The patient had to undergo a repeat invasive procedure and procedural sedation to exchange the cracked catheter for a new catheter.
Becton Dickinson, Brand name: BD First PICC Model 384232 The morning of the anticipated discharge, the patient's right saphenous PICC line (placed in the NICU by an IV RN 23 days prior to the event) was discovered to be fractured at the level of the hub. The line was visualized intact during morning rounds by the surgical team, but a short while later was discovered fractured when the patient's nurse undressed the patient for a diaper change. The internalized 20 cm fragment, proximal to the hub, migrated to her heart. This was confirmed by CXR projecting over the right atrium and right ventricle with one end within a left lower lobe pulmonary artery branch.
Bard Access Systems, Inc. Lot# RETI 0011/TD> The nurse was unable to thread the guide wire of a triple lumen catheter beyond 2-3 cm for PICC placement. The nurse was unable to remove the guide wire as well. A small incision was made to remove the guide wire. A knot was noted at the tip of the guide wire.
Bard Access Systems, Inc. Brand name: Per-Q-Cath Unknown A registered nurse went to remove a patient's PICC line (located on the patient's right upper extremity, removed one stitch and part of the PICC fell out. Twenty-five cm of the PICC line was retained by the patient. STAT x-rays were ordered and the PICC fragment was observed. The fragment was removed by Interventional Radiology. The patient is stable, with plans to be discharged back to the nursing home at the end of the week. The PICC was installed at the nursing home five days prior to the event
Bard Access Systems, Inc. Brand name: Groshong PICC insertion kit Catalog# 7617408, Lot# RETD0235 A nurse was opening a Groshong insertion pack and noticed a kink in the Groshong catheter. The nurse decided to use another Groshong catheter and there was no patient adverse event because the kink in the catheter was discovered prior to use.
Teleflex Medical Model/Catalog# PK-01452-W, Lot#RF8032592 Shearing of the plastic covering was noted at the insertion site involving the guide wire, making it unusable. A new kit was opened and a new site for insertion was selected. There were no further complications to the patient.
Bard Access Systems, Inc Lot# RESK0183 When flushing a dual lumen PICC with a 100cc pre-filled syringe utilizing a push-pause technique, the PICC line burst.
Cook Medical, Brand name: Spectrum Turbo-Ject Lot #’s 786511; 786845; 2268093; 2272821 The Spectrum Tubor-Ject PICC line was being trialed in the Infusion Therapy department. The catheter was going to be used for IV access for chemotherapy administration, antibiotic therapy and blood collection/draws. Thirty-six (36) catheters were placed in various types of patients. Twenty-two (22) of the thirty-six (36) patients experienced some kind of side effect that included a malposition of the catheter, clotting of the catheter and/or phlebitis. Five (5) patients developed a deep vein thrombosis requiring anticoagulation therapy. It was decided to discontinue the use of the catheter. It is thought that the tubing is too stiff possibly causing it to clot and malposition.
Bard Access Systems, Inc. Brand name: Solo PowerPICC Unknown The RN called the patient’s home to schedule an appointment with the patient and her husband said that the (single lumen) PICC IV line cap “cracked off” 2 days prior to the RN’s call. Our on- call RN had to bring a cap out to replace the one that cracked off. The on-call triage RN had the on-call RN go out to do a visit and replace the cap. The patient was receiving supplies while at the Ambulatory Infusion Clinic. With the PICC cap off that protects the patient; there is an increased risk for infection, air embolism, bleeding, etc. This was a "near miss" with what could have happened due to leaving an open line into the bloodstream uncovered. It leaves the patient seriously vulnerable to many potential problems that could even cause death. Since the patient receives her antibiotics at the Ambulatory Infusion Clinic, they usually do not get extra supplies for the home and the patient/patient caregiver are not routinely taught how to troubleshoot their PICC line care and maintenance. At the time of the cap change, the patient was afebrile and was receiving IV antibiotics through the PICC for left lower extremity deep vein thrombosis (DVT). Although the patient later developed septic arthritis three weeks after the cap change and received an additional course of antibiotics, the PICC was successfully discontinued about a week later without signs and symptoms of infection with orders for routine blood cultures x2 for three weeks.
Bard Access Systems, Inc. Brand name: DL Power Catalog# 3275108, Lot#RESI0865 Patient for PICC insertion was poked with echogenic needle. The guide wire would not thread through the needle which required a second stick with a different needle. After the procedure was completed and the needle was inspected, it appears that it was a bur on the guide wire that caused the problem.
Becton Dickinson Infusion Therapy Systems Catalog# 384224, Lot# 9125087 PICC line found in bed, which was broken at the hub.
Becton Dickinson Infusion Therapy Systems Catalog# 384224, Lot# 9125087 PICC line which was broken at the hub was found in the bed.
Becton Dickinson Infusion Therapies, Inc. Brand name: L-Catheter Catalog# 384539, Lot# 9029732 During a dressing check, the RN noted that the PICC line was leaking at the insertion site. The PICC line was in only 24 hours. The PICC line was removed and replaced.
Becton Dickinson Infusion Therapies, Inc. Brand name: L-Catheter Catalog# 384539, Lot#8241714 Upon dressing change, the RN noted leaking of the catheter under the lavender strain relief. The PICC line was removed.
Becton Dickinson Infusion Therapies, Inc. Brand name: L-Catheter Catalog# 384539, Lot# 8275035 Upon removal of a PICC line from a patient, the RN noted a 4.0 centimeter hole from the tip of the catheter.
Becton Dickinson Infusion Therapies, Inc. Brand name: L-Catheter Catalog# 384539, Lot# 8302104 Upon dressing change, the nurse noted leaking at the PICC line. The PICC line was discontinued.

Additional Information:

1. US FDA 510(k) Summary. June 30, 2010. Online Accessible:

http://www.accessdata.fda.gov/cdrh_docs/pdf9/K091586.pdf

2. US FDA 510(k) Summary. June 30, 2010. Online Accessible:

http://www.accessdata.fda.gov/cdrh_docs/pdf9/K091261.pdf

3. US FDA 510(k) Summary. June 30, 2010. Online Accessible:

http://www.accessdata.fda.gov/cdrh_docs/pdf8/K081690.pdf

4. US FDA 510(k) Summary. June 30, 2010. Online Accessible:

http://www.accessdata.fda.gov/cdrh_docs/pdf5/K051194.pdf


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