A 56-year-old man comes to the office due to pain, redness, and swelling in his right arm. The patient was recently diagnosed with unresectable lung cancer. He received the first cycle of chemotherapy 2 weeks ago through a right-sided peripherally inserted central catheter (PICC). Temperature is 36.9 C (98.4 F), blood pressure is 130/80 mm Hg, pulse is 78/min, and respirations are 14/min. Oxygen saturation is normal. Examination shows right arm swelling and mild erythema. Capillary refill is normal. No discharge is seen around the PICC line. The remainder of the examination is normal. Which of the following is the most appropriate next step in management?

Question

A 56-year-old man comes to the office due to pain, redness, and swelling in his right arm.  The patient was recently diagnosed with unresectable lung cancer.  He received the first cycle of chemotherapy 2 weeks ago through a right-sided peripherally inserted central catheter (PICC).  Temperature is 36.9 C (98.4 F), blood pressure is 130/80 mm Hg, pulse is 78/min, and respirations are 14/min.  Oxygen saturation is normal.  Examination shows right arm swelling and mild erythema.  Capillary refill is normal.  No discharge is seen around the PICC line.  The remainder of the examination is normal.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d91a_c58b_bc81_372d8631a816_MD0003_00 This patient's arm swelling, pain, and mild erythema developed in the setting of a peripherally inserted central catheter (PICC), raising strong suspicion for upper extremity deep venous thrombosis (DVT). All upper extremity central catheters (eg, internal jugular, subclavian) are associated with increased risk of DVT due to endothelial trauma during insertion and improper positioning of the catheter tip; the risk of DVT is somewhat higher with PICCs because they travel long distances through narrow peripheral veins (often occupying >50% of total vein caliber). Hospitalized patients, particularly those with a hypercoagulable state (eg, malignancy), are most likely to develop PICC-related DVT. Upper extremity DVT is most common within 7-14 days of PICC insertion. The primary manifestation is arm or forearm swelling. Pain and mild erythema may also occur. In contrast to PICC infection, patients with DVT usually have a normal appearing catheter insertion site (eg, no purulence). The diagnosis is made with compression or duplex ultrasonography, which visualizes the subclavian, axillary, and brachiocephalic veins. Although upper extremity DVT is associated with a relatively low risk of pulmonary embolism (~6%), treatment with 3 months of anticoagulation is recommended. The PICC line can often remain in place. (Choice A) Chest MRI can be used to diagnose superior vena cava (SVC) syndrome, which is often caused by lung malignancy. The SVC is not well visualized with ultrasound, although indirect findings (eg, waveforms) can suggest SVC occlusion. Although SVC syndrome is associated with increased risk of DVT, patients usually have dyspnea, chest pain, and/or face or neck swelling. (Choice C) Echocardiography is used to evaluate for structural defects of the heart. It is not routinely used in the evaluation of upper extremity DVT. Although PICC lines can be associated with bacteremia and resultant endocarditis, this diagnosis is unlikely in a patient who is afebrile and does not have a murmur. (Choice D) This patient with no fever or catheter site purulence is less likely to have infection. He should undergo duplex ultrasound to evaluate for DVT prior to consideration of empiric antibiotics for cellulitis. (Choice E) Superficial phlebitis can be treated with warm compresses and NSAIDs. It is generally caused by peripheral, not central, venous access and marked by redness along the peripheral vein. Arm swelling in the setting of PICC is far more likely to indicate DVT. Educational objective: Peripherally inserted central catheters increase the risk of upper extremity deep venous thrombosis. The risk is greatest in hospitalized patients, particularly those with malignancy or other hypercoagulable state. Manifestations include arm swelling, erythema, and pain. The diagnosis is made with duplex ultrasonography. Treatment with 3 months of anticoagulation is required.

A 56-Year-Old Man Comes to the Office Due to Pain