Trick of the Trade: The PIPP for deep peripheral IVs in obese patients

The Case

A 500-pound morbidly obese male presents to your ED complaining of mild shortness of breath and palpitations. A quick ECG shows SVT with a rate of 160 bpm. His BP is in the 130s systolic, and he is otherwise stable. You know you have a bit of time. Meanwhile, the nurses begin searching for veins to start an IV… 

The Problem

Multiple nurses try and fail to place a peripheral IV due to the patient’s obesity.  You know that you will need to push adenosine, so you will need a proximal line. His neck is so thick that finding an external jugular vein will be difficult. You think about central access, but he cannot lie flat to tolerate placement of an IJ line. Additionally, he has a massive inguinal hernia and sizable pannus, making a femoral line essentially out of the question. A subclavian line will be equally difficult given his size and lack of landmarks. 

You attempt ultrasound-guided deep peripheral IV placement with a long (1.88 inch) angiocath, but it keeps decannulating. It’s just not long enough to stay in the vein! You contemplate placing an intraosseous line into his humerus, but even his shoulder is obese, making landmarks difficult. Plus, you’d rather not have to drill into the bone of an awake patient, unless absolutely necessary. 

How can you secure vascular access in this patient? 

Trick of the Trade

Use a pediatric central venous catheter (CVC) placed under ultrasound guidance using the Seldinger technique into a deep arm vein. 

The pediatric CVC is 8 cm (3.15 in) in length, which gives the extra length you need to get from this patient’s skin into the vein. As an extra bonus, this is a double lumen catheter with 18- and 20- gauge lumens. This allows you to push the adenosine through one port and the saline flush through the second port- a pretty nifty set-up! After placement, the line was secured in place with a tissue adhesive glue and some steri-strips. Twelve milligrams of adenosine later, the patient was comfortably back in sinus rhythm. 

Placing this line is essentially like placing a short PICC. Call it a PIPP (Peripherally Inserted Peripheral Pediatric catheter)!

Authors: 
Noah Sugerman, MD (EM resident, UCLA/Olive-View) 
Eric Silman, MD (Assistant Program Director, UCLA/Olive-View EM residency) 

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