Adequate studies are not available to establish parameters for coagulation lab values before PICC placement. PICC insertion would have far less risk than other subclavian or IJ insertion sites if bleeding did occur. A PICC insertion site would allow for direct pressure in the event of bleeding while other sites would not, thus a PICC site is considered to be the best practice when there are risk of bleeding from high PT/PTT values or low platelets. For patients with bleeding tendency there are now products available that can be placed at the insertion site to control slow bleeding or oozing tendencies. Ultrasound use will direct the inserter away from arterial puncture, avoiding this risk. So a PICC is safer by far! Lynn
So would it be of any value to have any of these lab results priior to placing a PICC - if for no other reason that just to know if there was a bleeding tendency. If so, what would be the recommended time frame prior - at least within ______ hours prior to PICC placement.
This information will be helpful as I try to develop an order set for this procedure.
8.SANSIVERO, GAIL EGAN,; FEATURES AND SELECTION OF VASCULAR ACCESS DEVICES, Seminars in Oncology Nursing, Vol 26, No 2 (May), 2010: pp 88-101
9.Segal, Jodi B. and Dzik, Walter H. (Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Baltimore, MD 21205, USA.) Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Volume 45, September 2005 TRANSFUSION 1413-1425
11.LSUHSC, Nursing Policy: P-36, PERIPHERALLY INSERTED CENTRAL CATHETERS (PICC) CARE OF PATIENTS, June 2010, pg 3
12.Infusion Nurses Society, Nursing Practice Management™ 2008, pg 8
13.A Report by the American Society of Anesthesiologists Task Force on Central Venous Access*, Practice Guidelines for Central Venous Access pp 1-56
Author, date and country
Patient group
Study type (level of evidence)
Outcomes
Key results
Study Weaknesses
Gallieni M, Cozzolino M, 1995, Italy
10 patients had CVC inserted with the landmark technique, 31 patients had US-guided CVC insertion (12 high risk with coagulopathy).
Prospective observational study
Number of attempts.
13 cannulations in high risk patients successful at first attempt.
Single inexperienced operator. Small numbers.
Success rate.
100% success rate.
Complications.
No complications, except for 3 arterial punctures in landmark group and one in US group.
Della Vigna et al, 2008, Italy
157 patients with a disorder of haemostasis had 239 CV line insertions. Increased risk was defined as: PT/APTT 1.2x normal and/or plts<150.109/L High risk was defined as: PT/APTT>2.2x normal, and/or plts<50.109/L
Retrospective study
Number of passes.
122 CVCs inserted in haemostatic disorders (45 in high risk patients, 77 in increased risk patients).
A retrospective study performed by experienced radiologists. Oncology patients
Number and extent of complications.
No arterial puncture, no complications, no correction of coagulation parameters recorded.
Weigand et al, 2009, Germany
196 patients, 65 with disorders of haemostasis (PT≤50% or INR ≥1.5, platelets ≤50.109/L) had US-guided CVC insertion. Patients who had received FFP/RBC/plts within 24 hours were excluded.
Prospective study
Complication defined as > Hb 1.5g/dl drop 24-36 hours post-procedure. Compared mean platelet count between the group with Hb drop and those with no drop were similar for INR, PT.
No statistical difference for platelets, PT or INR groups (p=0.024, 0.164 and 0.363 respectively). A subgroup analysis of combined derangements showed no statistical difference either.
Number of patients with extreme values was too low to detect statistical significance.
Tercan et al, 2008, Turkey
133 US-guided CVC insertions in 119 patients with disorders of haemostasis (platelets ≤50.109/L, INR ≥1.5, APTT ≥50 alone or combined)
Prospective study
Number of attempts,
Average number of punctures 1.01 (range 1-2).
Study performed by interventional radiologists. 5 patients were lost to follow-up.
Success rate.
Success rate 100% (1st puncture 98.5% and 2nd 1.5%).
Minor complication rate 6% (oozing, haematoma). An association was found between high INR and haematoma rate (p<0.05). Platelet count, APTT, number of punctures, and diameter of line were not associated with haematoma (p>0.05).
Adequate studies are not available to establish parameters for coagulation lab values before PICC placement. PICC insertion would have far less risk than other subclavian or IJ insertion sites if bleeding did occur. A PICC insertion site would allow for direct pressure in the event of bleeding while other sites would not, thus a PICC site is considered to be the best practice when there are risk of bleeding from high PT/PTT values or low platelets. For patients with bleeding tendency there are now products available that can be placed at the insertion site to control slow bleeding or oozing tendencies. Ultrasound use will direct the inserter away from arterial puncture, avoiding this risk. So a PICC is safer by far! Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
So would it be of any value to have any of these lab results priior to placing a PICC - if for no other reason that just to know if there was a bleeding tendency. If so, what would be the recommended time frame prior - at least within ______ hours prior to PICC placement.
This information will be helpful as I try to develop an order set for this procedure.
Barbara
Education Coordinator
Harlingen Medical Center, Texas
so should we be checking these lab values?
I researched this last year .......... here are some of my references. Good Luck!
1. Infusion Nurses Society: "Infusion Nursing Standards of Practice”. Journal of Infusion Nursing, 32,33,35. 2011
2. Registered Nurses Association of Ontario, Assessment and Device Selection for Vascular Access with 2008 Supplement.pdf, May 2004 pp. 1-74.
3. Royal College of Nursing, The RCN IV Therapy Forum, Standards for infusion therapy, Third edition, January 2010, pp. 1-102
4. Aaronson, Michael, Volume Status in the Intensive Care Unit: Central Venous Pressure (CVP) vs. Right Atrial Pressure vs.Vena Caval Index, www.michaelaaronsonmd.com Saturday, October 2nd, 2010
5. Bowe-Geddes, Leigh A.; Nichols, Heather A., An Overview of Peripherally Inserted Central Catheters, Posted: 08/17/2005; Topics in Advanced Practice Nursing eJournal. 2005;5(3) © 2005 Medscape
6. GIORGETTI, G.M., GRAVANTE, G., PITTIRUTI, M.,; Peripherally inserted central catheters and midline catheters in artificial nutrition. Indications and limits. Nutritional Therapy & Metabolism /2006, Vol. 24 no. 4, pp. 164-167.
7. Moureau, Nancy, Critical Thinking: Insertional Assessment for PICCs & IV Tx, http://www.avainfo.org/website/article.asp?id=57267
8. SANSIVERO, GAIL EGAN,; FEATURES AND SELECTION OF VASCULAR ACCESS DEVICES, Seminars in Oncology Nursing, Vol 26, No 2 (May), 2010: pp 88-101
9. Segal, Jodi B. and Dzik, Walter H. (Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Baltimore, MD 21205, USA.) Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Volume 45, September 2005 TRANSFUSION 1413-1425
10. When To Use PICCs: IV Infusions for patient with bleeding disorders no matter the PTT or INR http://www.piccexcellence.com/piccinfo/picc_info.php
11. LSUHSC, Nursing Policy: P-36, PERIPHERALLY INSERTED CENTRAL CATHETERS (PICC) CARE OF PATIENTS, June 2010, pg 3
12. Infusion Nurses Society, Nursing Practice Management™ 2008, pg 8
13. A Report by the American Society of Anesthesiologists Task Force on Central Venous Access*, Practice Guidelines for Central Venous Access pp 1-56
Author, date and country
Patient group
Study type (level of evidence)
Outcomes
Key results
Study Weaknesses
Gallieni M, Cozzolino M,
1995,
Italy
10 patients had CVC inserted with the landmark technique, 31 patients had US-guided CVC insertion (12 high risk with coagulopathy).
Prospective observational study
Number of attempts.
13 cannulations in high risk patients successful at first attempt.
Single inexperienced operator. Small numbers.
Success rate.
100% success rate.
Complications.
No complications, except for 3 arterial punctures in landmark group and one in US group.
Della Vigna et al,
2008,
Italy
157 patients with a disorder of haemostasis had 239 CV line insertions. Increased risk was defined as: PT/APTT 1.2x normal and/or plts<150.109/L High risk was defined as: PT/APTT>2.2x normal, and/or plts<50.109/L
Retrospective study
Number of passes.
122 CVCs inserted in haemostatic disorders (45 in high risk patients, 77 in increased risk patients).
A retrospective study performed by experienced radiologists. Oncology patients
Number and extent of complications.
No arterial puncture, no complications, no correction of coagulation parameters recorded.
Weigand et al,
2009,
Germany
196 patients, 65 with disorders of haemostasis (PT≤50% or INR ≥1.5, platelets ≤50.109/L) had US-guided CVC insertion. Patients who had received FFP/RBC/plts within 24 hours were excluded.
Prospective study
Complication defined as > Hb 1.5g/dl drop 24-36 hours post-procedure. Compared mean platelet count between the group with Hb drop and those with no drop were similar for INR, PT.
No statistical difference for platelets, PT or INR groups (p=0.024, 0.164 and 0.363 respectively). A subgroup analysis of combined derangements showed no statistical difference either.
Number of patients with extreme values was too low to detect statistical significance.
Tercan et al,
2008,
Turkey
133 US-guided CVC insertions in 119 patients with disorders of haemostasis (platelets ≤50.109/L, INR ≥1.5, APTT ≥50 alone or combined)
Prospective study
Number of attempts,
Average number of punctures 1.01 (range 1-2).
Study performed by interventional radiologists. 5 patients were lost to follow-up.
Success rate.
Success rate 100% (1st puncture 98.5% and 2nd 1.5%).
Recorded single or double-wall puncture.
Single-wall puncture 89.5%, double-wall puncture 10.5%.
complications within 24 hours,
Minor complication rate 6% (oozing, haematoma). An association was found between high INR and haematoma rate (p<0.05). Platelet count, APTT, number of punctures, and diameter of line were not associated with haematoma (p>0.05).