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JAMA Surgery Clinical Challenge
November 2017

Arm Swelling Following Attempted Peripherally Inserted Central Catheter

Author Affiliations
  • 1St John Macomb Hospital, Warren, Michigan
  • 2St John Macomb Hospital, West Bloomfield, Michigan
JAMA Surg. 2017;152(11):1074-1075. doi:10.1001/jamasurg.2017.3372

An elderly woman was transferred from an extended care facility with lower abdominal pain. She was afebrile with a heart rate of 120 beats/min on admission and leukocytosis (white blood cell count, 23 000/μL [to convert to ×109/L, multiply by 0.001]). Computed tomography of the abdomen and pelvis and transvaginal ultrasonography revealed a large intrauterine abscess. An attempt to insert a peripherally inserted central catheter (PICC) into the right basilic vein was unsuccessful. An intravenous catheter in the left hand was established for the administration of antibiotics. The following day, the patient developed right upper extremity pain and swelling. Physical examination revealed tense and tender swelling of the right upper extremity that was more marked in the upper arm and caused significant impairment in motor function, but sensation to touch and pin prick was intact (Figure 1A). The right radial pulse was absent, but biphasic Doppler arterial signals were present in the right radial and ulnar artery. Duplex ultrasonographic imaging of the right upper extremity demonstrated a 12.8 × 2.6-cm heterogeneous fluid collection with active color flow (Figure 1B).

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